exam 2 NCLEX questions

A nurse is to administer 40 mg of furosemide (Lasix®) to a client in heart failure. The prefilled syringe reads 100 mg/mL. In order to give the correct dose, the nurse should administer ____mL to the client.

0.4mL

Which assessment data indicate the client diagnosed with diabetic ketoacidosis is responding to the medical treatment? 1. The client has tented skin turgor and dry mucous membranes. 2. The client is alert and oriented to date, time, and place. 3. The client's ABG results are pH 7.29, Paco2 44, HCO3 15. 4. The client's serum potassium level is 3.3 mEq/L.

2

Which of the following is an expected outcome when a client is receiving an IV administration of furosemide? 1. Increased blood pressure. 2. Increased urine output. 3. Decreased pain. 4. Decreased premature ventricular contractions.

2 Furosemide is a loop diuretic that acts to increase urine output. Furosemide does not increase blood pressure, decrease pain, or decrease arrhythmias.

Which electrolyte replacement should the nurse anticipate being ordered by the health-care provider in the client diagnosed with diabetic ketoacidosis (DKA) who has just been admitted to the ICU? 1. Glucose. 2. Potassium. 3. Calcium. 4. Sodium.

2.

Which of the following is not a risk factor for the development of atherosclerosis? 1. Family history of early heart attack. 2. Late onset of puberty. 3. Total blood cholesterol level greater than 220 mg/dL (12.2 mmol/L). 4. Elevated fasting blood glucose concentration.

2.Late onset of puberty is not generally considered to be a risk factor for the development of atherosclerosis. Risk factors for atherosclerosis include family history of atherosclerosis, cigarette smoking, hypertension, high blood cholesterol level, male gender, diabetes mellitus, obesity, and physical inactivity.

The charge nurse is making client assignments in the intensive care unit. Which client should be assigned to the most experienced nurse? 1. The client with type 2 diabetes who has a blood glucose level of 348 mg/dL. 2. The client diagnosed with type 1 diabetes who is experiencing hypoglycemia. 3. The client with DKA who has multifocal premature ventricular contractions. 4. The client with HHN who has a plasma osmolarity of 290

3

The nurse is assessing the feet of a client with long-term type 2 diabetes. Which assessment data warrant immediate intervention by the nurse? 1. The client has crumbling toenails. 2. The client has athlete's foot. 3. The client has a necrotic big toe. 4. The client has thickened toenails.

3

The client diagnosed with type 2 diabetes is admitted to the intensive care unit (ICU) with hyperosmolar hyperglycemic nonketotic syndrome (HHNS) coma. Which assessment data should the nurse expect the client to exhibit? 1. Kussmaul's respirations. 2. Diarrhea and epigastric pain. 3. Dry mucous membranes. 4. Ketone breath odor.

3.

47. A nurse is teaching a client with type 1 diabetes mellitus who jogs daily about the preferred sites for insulin absorption. What is the most appropriate site for a client who jogs? 1. Arms. 2. Legs. 3. Abdomen. 4. Iliac crest.

3. If the client engages in an activity or exercise that focuses on one area of the body, that area may cause inconsistent absorption of insulin. A good regimen for a jogger is to inject the abdomen for 1 week and then rotate to the buttock. A jogger may have inconsistent absorption in the legs or arms with strenuous running. The iliac crest is not an appropriate site due to a lack of loose skin and subcutaneous tissue in that area.

The nurse is instructing the client on insulin administration. The client is performing a return demonstration for preparing the insulin. The client's morning dose of insulin is 10 units of regular and 22 units of NPH. The nurse checks the dose accuracy with the client. The nurse determines that the client has prepared the correct dose when the syringe reads how many units? ____________________ units.

32 units

56. A client with diabetes begins to cry and says, "I just cannot stand the thought of having to give myself a shot every day." Which of the following would be the best response by the nurse? 1. "If you do not give yourself your insulin shots, you will die." 2. "We can teach your daughter to give the shots so you will not have to do it." 3. "I can arrange to have a home care nurse give you the shots every day." 4. "What is it about giving yourself the insulin shots that bothers you?"

4. 4. The best response is to allow the client to verbalize her fears about giving herself a shot each day. Tactics that increase fear are not effective in changing behavior. If possible, the client needs to be responsible for her own care, including giving self- injections. It is unlikely that the client's insurance company will pay for home-care visits if the client is capable of self-administration.

A nurse is teaching a client experiencing hypoparathyroidism resulting from a lack of parathyroid hormone (PTH) about foods to consume. Which should be included on a list of appropriate foods for a client experiencing hypoparathyroidism? 1. Dark green vegetables, soybeans, and tofu 2. Spinach, strawberries, and yogurt 3. Whole grain bread, milk, and liver 4. Rhubarb, yellow vegetables, and fish

ANSWER: 1 Hypoparathyroidism from lack of PTH produces chronic hypocal- cemia. Foods consumed should be high in calcium. Foods containing oxalic acid (spinach, rhubarb), and phytic acid (whole grains) reduce calcium absorption. ➧ Test-taking Tip: Recall that hypoparathyroidism produces hypocalcemia.

The client is admitted to the ICU diagnosed with DKA. Which interventions should the nurse implement? Select all that apply. 1. Maintain adequate ventilation. 2. Assess fluid volume status. 3. Administer intravenous potassium. 4. Check for urinary ketones. 5. Monitor intake and output

All

40. Which of the following findings should the nurse report to the client's physician for a client with unstable type 1 diabetes mellitus? Select all that apply. 1. Systolic blood pressure, 145 mm Hg. 2. Diastolic blood pressure, 87 mm Hg. 3. High-density lipoprotein (HDL), 30 mg/dL (1.7 mmol/L). 4. Glycosylated hemoglobin (HbA1c), 10.2% (0.1). 5. Triglycerides, 425 mg/dL (23.6 mmol/L). 6. Urine ketones, negative.

1, 2, 3, 4, 5 The client with unstable diabetes mellitus is at risk for many complications. Heart disease is the leading cause of mortality in clients with diabetes. The goal blood pressure for diabetics is less than 130/80 mm Hg. Therefore, the nurse would need to report any findings greater than 130/80 mm Hg. The goal of HbA1c is less than 7% (0.07); thus, a level of 10.2% (0.1) must be reported. HDL less than 40 mg/dL (2.2 mmol/L) and triglycerides greater than 150 mg/dL (8.3 mmol/L) are risk factors for heart disease. The nurse would need to report the client's HDL and triglyceride levels. The urine ketones are negative, but this is a late sign of complications when there is a profound insulin deficiency.

3. Of the clients listed below, who is at risk for developing rheumatoid arthritis (RA)? Select all that apply. 1. Adults between the ages of 20 and 50 years. 2. Adults who have had an infectious disease with the Epstein-Barr virus. 3. Adults who are of the male gender. 4. Adults who possess the genetic link, specifically HLA-DR4. 5. Adults who also have osteoarthritis.

1, 2, 4 RA affects women three times more often than men between the ages of 20 and 55 years. Research has determined that RA occurs in clients who have had infectious disease, such as the Epstein-Barr virus. The genetic link, specifically HLA-DR4, has been found in 65% of clients with RA. People with osteoarthritis are not necessarily at risk for developing RA.

The diabetic educator is teaching a class on diabetes type 1 and is discussing sick-day rules. Which interventions should the diabetes educator include in the discussion? Select all that apply. 1. Take diabetic medication even if unable to eat the client's normal diabetic diet. 2. If unable to eat, drink liquids equal to the client's normal caloric intake. 3. It is not necessary to notify the health-care provider (HCP) if ketones are in the urine. 4. Test blood glucose levels and test urine ketones once a day and keep a record. 5. Call the health-care provider if glucose levels are higher than 180 mg/dL.

1, 2, 5

12. Which of the following statements should the nurse include in the teaching session when preparing a client for arthrocentesis? Select all that apply. 1. "A local anesthetic agent may be injected into the joint site for your comfort." 2. "A syringe and needle will be used to withdraw fluid from your joint." 3. "The procedure, although not painful, will provide immediate relief." 4. "We'll want you to keep your joint active after the procedure to increase blood flow." 5. "You will need to wear a compression bandage for several days after the procedure."

1, 2, 5 An arthrocentesis is performed to aspirate excess synovial fluid, pus, or blood from a joint cavity to relieve pain or to diagnosis inflammatory diseases such as rheumatoid arthritis. A local agent may be used to decrease the pain of the needle insertion through the skin and into the joint cavity. Aspiration of the fluid into the syringe can be very painful because of the size and inflammation of the joint. Usually a steroid medication is injected locally to alleviate the inflammation; a compression bandage is applied to help decrease swelling; and the client is asked to rest the joint for up to 24 hours afterward to help relieve the pain and promote rest to the inflamed joint. The client may experience pain during this time until the inflammation begins to resolve and swelling decreases.

4. A client is in the acute phase of rheumatoid arthritis. In which order of priority should the nurse establish the following goals? 1. Relieving pain. 2. Preserving joint function. 3. Maintaining usual ways of accomplishing tasks. 4. Preventing joint deformity.

1, 4, 2, 3 Pain relief is the highest priority during the acute phase because pain is typically severe and interferes with the client's ability to function. Preserving joint function is the next goal to set, followed by preventing joint deformity during the acute phase to promote an optimal level of functioning and reduce the risk of contractures. Maintaining usual ways of accomplishing tasks is the goal with the lowest priority during the acute phase. Rather, the focus is on developing less stressful ways of accomplishing routine tasks.

30. Which information should the nurse include when developing a teaching plan for a client newly diagnosed with type 2 diabetes mellitus? Select all that apply. 1. A major risk factor for complications is obesity and central abdominal obesity. 2. Supplemental insulin is mandatory for controlling the disease. 3. Exercise increases insulin resistance. 4. The primary nutritional source requiring monitoring in the diet is carbohydrates. 5. Annual eye and foot examinations are recommended by the American and Canadian Diabetes Associations.

1, 5 Being overweight and having a large waist-hip ratio (central abdominal obesity) increase insulin resistance, making control of diabetes more difficult. The American and Canadian Diabetes Associations recommend a yearly referral to an ophthalmologist and podiatrist. Exercise and weight management decrease insulin resistance. Insulin is not always needed for type 2 diabetes; diet, exercise, and oral medications are the first-line treatment. The client must monitor all nutritional sources for a balanced diet—fats, carbohydrates, and protein.

The elderly client is admitted to the intensive care department diagnosed with severe HHNS. Which collaborative intervention should the nurse include in the plan of care? 1. Infuse 0.9% normal saline intravenously. 2. Administer intermediate-acting insulin. 3. Perform blood glucometer checks daily. 4. Monitor arterial blood gas (ABG) results.

1.

The home health nurse is completing the admission assessment for a 76-year-old client diagnosed with type 2 diabetes controlled with 70/30 insulin. Which intervention should be included in the plan of care? 1. Assess the client's ability to read small print. 2. Monitor the client's serum prothrombin time (PT) level. 3. Teach the client how to perform a hemoglobin A1c test daily. 4. Instruct the client to check the feet weekly.

1.

The nurse is developing a care plan for the client diagnosed with type 1 diabetes. The nurse identifies the problem "high risk for hyperglycemia related to noncompliance with the medication regimen." Which statement is an appropriate short-term goal for the client? 1. The client will have a blood glucose level between 90 and 140 mg/dL. 2. The client will demonstrate appropriate insulin injection technique. 3. The nurse will monitor the client's blood glucose levels four (4) times a day. 4. The client will maintain normal kidney function with 30-mL/hr urine output

1.

27. The client with type 2 insulin-requiring diabetes asks the nurse about having alcoholic beverages. Which of the following is the best response by the nurse? 1. "You can have one or two drinks a day as long as you have something to eat with them." 2. "Alcohol is detoxified in the liver, so it is not a good idea for you to drink anything with alcohol." 3. "If you are going to have a drink, it is best to consume alcohol on an empty stomach." 4. "If you do have a drink, the blood glucose value may be elevated at bedtime, and you should skip having a snack."

1. A modest alcohol intake (1 to 2 drinks/day) may be incorporated into the nutrition plan for individuals who choose to drink. Alcohol is detoxified in the liver where glycogen reserves are stored and normally released in case of hypoglycemia. At the time alcohol is consumed, glucose values will likely rise because of the carbohydrate in the beer, wine or mixed drinks; however, the later and more dangerous effect of alcohol is a hypoglycemic effect. Alcohol should be consumed with food; even if blood glucose values are elevated, the bedtime snack should not be skipped.

28. An adult client with type 2 diabetes is taking metformin (Glucophage) 1,000 mg two times every day. After the nurse provides instructions regarding the interaction of alcohol and metformin, the nurse evaluates that the client understands the instructions when the client says: 1. "If I know I'll be having alcohol, I must not take metformin; I could develop lactic acidosis." 2. "If my physician approves, I may drink alcohol with my metformin." 3. "Adverse effects I should watch for are feeling excessively energetic, unusual muscle stiffness, low back pain, and a rapid heartbeat." 4. "If I feel bloated, I should call my physician."

1. A rare but serious adverse effect of metformin (Glucophage) is lactic acidosis; half the cases are fatal. Ideally, one should stop metformin for 2 days before and 2 days after drinking alcohol. Signs and symptoms of lactic acidosis are weakness, fatigue, unusual muscle pain, dyspnea, unusual stomach discomfort, dizziness or light-headedness, and bradycardia or cardiac arrhythmias. Bloating is not an adverse effect of metformin.

2. A client with rheumatoid arthritis states, "I can't do my household chores without becoming tired. My knees hurt whenever I walk." Which goal for this client should take priority?. 1. Conserve energy. 2. Adapt self-care skills. 3. Develop coping skills. 4. Adapt body image.

1. Based on the information from the client, the nurse should develop a plan with the client that will conserve energy and decrease episodes of fatigue. Although the client may develop a self-care deficit related to the increasing joint pain, the client is voicing concerns about household chores and difficulty around the house and yard, not self-care issues. Over time, the client may have difficulty coping or experience changes in body image as the disorder becomes chronic with increasing pain and fatigue, but the current priority is to conserve energy.

9. After teaching the client with severe rheumatoid arthritis about prescribed methotrexate, which of the following statements indicates the need for further teaching?. 1. "I will take my vitamins while I'm on this drug." 2. "I must not drink any alcohol while I'm taking this drug." 3. "I should brush my teeth after every meal." 4. "I will continue taking my birth control pills."

1. Because some over-the-counter vitamin supplements contain folic acid, the client should avoid self-medication with vitamins while taking methotrexate, a folic acid antagonist. Because methotrexate is hepatotoxic, the client should avoid the intake of alcohol, which could increase the risk for hepatotoxicity. Methotrexate can cause bone marrow depression, placing the client at risk for infection. Therefore, meticulous mouth care is essential to minimize the risk of infection. Contraception should be used during methotrexate therapy and for 8 weeks after the therapy has been discontinued because of its effect on mitosis. Methotrexate is considered teratogenic.

The nurse administered 28 units of Humulin N, an intermediate-acting insulin, to a client diagnosed with type 1 diabetes at 1600. Which intervention should the nurse implement? 1. Ensure the client eats the bedtime snack. 2. Determine how much food the client ate at lunch. 3. Perform a glucometer reading at 0700. 4. Offer the client protein after administering insulin.

1. Ensure the client eats the bedtime snack.

48. A client with diabetes is taking insulin lispro (Humalog) injections. The nurse should advise the client to eat: 1. Within 10 to 15 minutes after the injection. 2. 1 hour after the injection. 3. At any time, because timing of meals with lispro injections is unnecessary. 4. 2 hours before the injection.

1. Insulin lispro (Humalog) begins to act within 10 to 15 minutes and lasts approximately 4 hours. A major advantage of Humalog is that the client can eat almost immediately after the insulin is administered. The client needs to be instructed regarding the onset, peak, and duration of all insulin, as meals need to be timed with these parameters. Waiting 1 hour to eat may precipitate hypoglycemia. Eating 2 hours before the insulin lispro could cause hyperglycemia if the client does not have circulating insulin to metabolize the carbohydrate.

31. When teaching the diabetic client about foot care, the nurse should instruct the client to do which of the following? 1. Avoid going barefoot. 2. Buy shoes a half size larger. 3. Cut toenails at angles. 4. Use heating pads for sore feet.

1. The client with diabetes is prone to serious foot injuries secondary to peripheral neuropathy and decreased circulation. The client should be taught to avoid going barefoot to prevent injury. Shoes that do not fit properly should not be worn because they will cause blisters that can become nonhealing, serious wounds for the diabetic client. Toenails should be cut straight across. A heating pad should not be used because of the risk of burns due to insensitivity to temperature.

52. The nurse should teach the diabetic client that which of the following is the most common symptom of hypoglycemia? 1. Nervousness. 2. Anorexia. 3. Kussmaul's respirations. 4. Bradycardia.

1. The four most commonly reported signs and symptoms of hypoglycemia are nervousness, weakness, perspiration, and confusion. Other signs and symptoms include hunger, incoherent speech, tachycardia, and blurred vision. Anorexia and Kussmaul's respirations are clinical manifestations of hyperglycemia or ketoacidosis. Bradycardia is not associated with hypoglycemia; tachycardia is.

The client diagnosed with type 1 diabetes is found lying unconscious on the floor of the bathroom. Which intervention should the nurse implement first? 1. Administer 50% dextrose (IVP). 2. Notify the health-care provider. 3. Move the client to the ICU. 4. Check the serum glucose level

1. The nurse should assume the client is hypoglycemic and administer IVP dextrose, which will rouse the client immediately. If the collapse is the result of hyperglycemia, this additional dextrose will not further injure the client.

55. Which of the following is a priority goal for the diabetic client who is taking insulin and has nausea and vomiting from a viral illness or influenza? 1. Obtaining adequate food intake. 2. Managing own health. 3. Relieving pain. 4. Increasing activity.

1. The priority goal for the client with diabetes mellitus who is experiencing vomiting with influenza is to obtain adequate nutrition. The diabetic client should eat small, frequent meals of 50 g of carbohydrate or food equal to 200 cal every 3 to 4 hours. If the client cannot eat the carbohydrates or take fluids, the health care provider should be called or the client should go to the emergency department. The diabetic client is in danger of complications with dehydration, electrolyte imbalance, and ketoacidosis. Increasing the client's health management skills is important to lifestyle behaviors, but it is not a priority during this acute illness of influenza. Pain relief may be a need for this client, but it is not the priority at this time; neither is increasing activity during the illness.

44. The nurse is teaching the client about home blood glucose monitoring. Which of the following blood glucose measurements indicates hypoglycemia? 1. 59 mg/dL (3.3 mmol/L). 2. 75 mg/dL (4.2 mmol/L). 3. 108 mg/dL (6 mmol/L). 4. 119 mg/dL (6.6 mmol/L).

1.Although some individual variation exists, when the blood glucose level decreases to less than 70 mg/dL (3.9 mmol/L), the client experiences or is at risk for hypoglycemia. Hypoglycemia can occur in both type 1 and type 2 diabetes mellitus, although it is more common when the client is taking insulin. The nurse should instruct the client on the prevention, detection, and treatment of hypoglycemia.

54. A client with type 1 diabetes mellitus has influenza. The nurse should instruct the client to: 1. Increase the frequency of self-monitoring (blood glucose testing). 2. Reduce food intake to diminish nausea. 3. Discontinue that dose of insulin if unable to eat. 4. Take half of the normal dose of insulin.

1.Colds and influenza present special challenges to the client with diabetes mellitus because the body's need for insulin increases during illness. Therefore, the client must take the prescribed insulin dose, increase the frequency of blood glucose testing, and maintain an adequate fluid intake to counteract the dehydrating effect of hyperglycemia. Clear fluids, juices, and Gatorade are encouraged. Not taking insulin when sick, or taking half the normal dose, may cause the client to develop ketoacidosis.

35. A client with type 1 diabetes mellitus is admitted to the emergency department. Which of the following respiratory patterns requires immediate action? 1. Deep, rapid respirations with long expirations. 2. Shallow respirations alternating with long expirations. 3. Regular depth of respirations with frequent pauses. 4. Short expirations and inspirations.

1.Deep, rapid respirations with long expirations are indicative of Kussmaul's respirations, which occur in metabolic acidosis. The respirations increase in rate and depth, and the breath has a "fruity" or acetone-like odor. This breathing pattern is the body's attempt to blow off carbon dioxide and acetone, thus compensating for the acidosis. The other breathing patterns listed are not related to ketoacidosis and would not compensate for the acidosis.

49. The best indicator that the client has learned how to give an insulin self-injection correctly is when the client can: 1. Perform the procedure safely and correctly. 2. Critique the nurse's performance of the procedure. 3. Explain all steps of the procedure correctly. 4. Correctly answer a posttest about the procedure.

1.The nurse should judge that learning has occurred from the evidence of a change in the client's behavior. A client who performs a procedure safely and correctly demonstrates that he has acquired a skill. Evaluation of this skill acquisition requires performance of that skill by the client with observation by the nurse. The client must also demonstrate cognitive understanding, as shown by the ability to critique the nurse's performance. Explaining the steps demonstrates acquisition of knowledge at the cognitive level only. A posttest does not indicate the degree to which the client has learned a psychomotor skill

The UAP on the medical floor tells the nurse the client diagnosed with DKA wants something else to eat for lunch. Which intervention should the nurse implement? 1. Instruct the UAP to get the client additional food. 2. Notify the dietitian about the client's request. 3. Request the HCP increase the client's caloric intake. 4. Tell the UAP the client cannot have anything else.

2

The nurse at a freestanding health-care clinic is caring for a 56-year-old male client who is homeless and is a type 2 diabetic controlled with insulin. Which action is an example of client advocacy? 1. Ask the client if he has somewhere he can go and live. 2. Arrange for someone to give him insulin at a local homeless shelter. 3. Notify Adult Protective Services about the client's situation. 4. Ask the HCP to take the client off insulin because he is homeless.

2.

32. A client with diabetes mellitus asks the nurse to recommend something to remove corns from the toes. The nurse should advise the client to: 1. Apply a high-quality corn plaster to the area. 2. Consult a physician or podiatrist about removing the corns. 3. Apply iodine to the corns before peeling them off. 4. Soak the feet in borax solution to peel off the corns.

2. 2. A client with diabetes should be advised to consult a physician or podiatrist for corn removal because of the danger of traumatizing the foot tissue and potential development of ulcers. The diabetic client should never self-treat foot problems but should consult a physician or podiatrist.

Prior to administering tissue plasminogen activator (t-PA), the nurse should assess the client for which of the following contradictions to administering the drug? 1. Age greater than 60 years. 2. History of cerebral hemorrhage. 3. History of heart failure. 4. Cigarette smoking.

2. A history of cerebral hemorrhage is a contraindication to administration of t-PA because the risk of hemorrhage may be further increased. Age greater than 60 years, history of heart failure, and cigarette smoking are not contraindications.

10. A 25-year-old client taking hydroxychloroquine (Plaquenil) for rheumatoid arthritis reports difficulty seeing out of the left eye. Correct interpretation of this assessment finding indicates which of the following?. 1. Development of a cataract. 2. Possible retinal degeneration. 3. Part of the disease process. 4. A coincidental occurrence.

2. Difficulty seeing out of one eye, when evaluated in conjunction with the client's medication therapy regimen, leads to the suspicion of possible retinal degeneration. The possibility of an irreversible retinal degeneration caused by deposits of hydroxychloroquine (Plaquenil) in the layers of the retina requires an ophthalmologic examination before therapy is begun and at 6-month intervals. Although cataracts may develop in young adults, they are less likely, and damage from the hydroxychloroquine is the most obvious at-risk factor. Eyesight is not affected by the disease process of rheumatoid arthritis

The client with type 2 diabetes controlled with biguanide oral diabetic medication is scheduled for a computed tomography (CT) scan with contrast of the abdomen to evaluate pancreatic function. Which intervention should the nurse implement? 1. Provide a high-fat diet 24 hours prior to test. 2. Hold the biguanide medication for 48 hours prior to test. 3. Obtain an informed consent form for the test. 4. Administer pancreatic enzymes prior to the test.

2. Hold the biguanide medication for 48 hours prior to test.

33. A client with diabetes mellitus comes to the clinic for a regular 3-month follow-up appointment. The nurse notes several small bandages covering cuts on the client's hands. The client says, "I'm so clumsy. I'm always cutting my finger cooking or burning myself on the iron." Which of the following responses by the nurse would be most appropriate? 1. "Wash all wounds in isopropyl alcohol." 2. "Keep all cuts clean and covered." 3. "Why don't you have your children do the cooking and ironing?" 4. "You really should be fine as long as you take your daily medication."

2. Proper and careful first-aid treatment is important when a client with diabetes has a skin cut or laceration. The skin should be kept supple and as free of organisms as possible. Washing and bandaging the cut will accomplish this. Washing wounds with alcohol is too caustic and drying to the skin. Having the children help is an unrealistic suggestion and does not educate the client about proper care of wounds. Tight control of blood glucose levels through adherence to the medication regimen is vitally important; however, it does not mean that careful attention to cuts can be ignored.

53. The nurse is assessing the client's use of medications. Which of the following medications may cause a complication with the treatment plan of a client with diabetes? 1. Aspirin. 2. Steroids. 3. Sulfonylureas. 4. Angiotensin-converting enzyme (ACE) inhibitors.

2. Steroids can cause hyperglycemia because of their effects on carbohydrate metabolism, making diabetic control more difficult. Aspirin is not known to affect glucose metabolism. Sulfonylureas are oral hypoglycemic agents used in the treatment of diabetes mellitus. ACE inhibitors are not known to affect glucose metabolism.

An 18-year-old female client, 5′4′′ tall, weighing 113 kg, comes to the clinic for a nonhealing wound on her lower leg, which she has had for two (2) weeks. Which disease process should the nurse suspect the client has developed? 1. Type 1 diabetes. 2. Type 2 diabetes. 3. Gestational diabetes. 4. Acanthosis nigricans.

2. Type 2 diabetes.

43. Which of the following indicates a potential complication of diabetes mellitus? 1. Inflamed, painful joints. 2. Blood pressure of 160/100 mm Hg. 3. Stooped appearance. 4. Hemoglobin of 9 g/dL (90 g/L).

2.The client with diabetes mellitus is especially prone to hypertension due to atherosclerotic changes, which leads to problems of the microvascular and macrovascular systems. This can result in complications in the heart, brain, and kidneys. Heart disease and stroke are twice as common among people with diabetes mellitus as among people without the disease. Painful, inflamed joints accompany rheumatoid arthritis. A stooped appearance accompanies osteoporosis with narrowing of the vertebral column. A low hemoglobin concentration accompanies anemia, especially iron deficiency anemia and anemia of chronic disease.

The client received 10 units of Humulin R, a fast-acting insulin, at 0700. At 1030 the unlicensed assistive personnel (UAP) tells the nurse the client has a headache and is really acting "funny." Which intervention should the nurse implement first? 1. Instruct the UAP to obtain the blood glucose level. 2. Have the client drink eight (8) ounces of orange juice. 3. Go to the client's room and assess the client for hypoglycemia. 4. Prepare to administer one (1) ampule 50% dextrose intravenously.

3

The emergency department nurse is caring for a client diagnosed with HHNS who has a blood glucose of 680 mg/dL. Which question should the nurse ask the client to determine the cause of this acute complication? 1. "When is the last time you took your insulin?" 2. "When did you have your last meal?" 3. "Have you had some type of infection lately?" 4. "How long have you had diabetes

3

The nurse is discussing ways to prevent diabetic ketoacidosis with the client diagnosed with type 1 diabetes. Which instruction is most important to discuss with the client? 1. Refer the client to the American Diabetes Association. 2. Do not take any over-the-counter (OTC) medications. 3. Take the prescribed insulin even when unable to eat because of illness. 4. Explain the need to get the annual flu and pneumonia vaccines.

3

The client diagnosed with type 1 diabetes is receiving Humalog, a rapid-acting insulin, by sliding scale. The order reads blood glucose level: <150, zero (0) units; 151 to 200, three (3) units; 201 to 250, six (6) units; >251, contact health-care provider. The unlicensed assistive personnel (UAP) reports to the nurse the client's glucometer reading is 189. How much insulin should the nurse administer to the client?

3 units

36. The client has been recently diagnosed with type 2 diabetes, and is taking metformin (Glucophage) two times per day, 1,000 mg before breakfast and 1,000 mg before supper. The client is experiencing diarrhea, nausea, vomiting, abdominal bloating, and anorexia on admission to the hospital. The admission prescriptions include metformin (Glucophage). The nurse should do which of the following? Select all that apply. 1. Discontinue the metformin (Glucophage). 2. Administer glargine (Lantus) insulin rather than the metformin (Glucophage). 3. Inform the client that the adverse effects of diarrhea, nausea, and upset stomach gradually subside over time. 4. Assess the client's renal function. 5. Monitor the client's glucose value prior to each meal.

3, 4, 5 The nurse may not discontinue a medication without a physician's prescription, and the nurse may not substitute one medication for another. Maximum doses may be better tolerated if given with meals. Before therapy begins, and at least annually thereafter, assess the client's renal function; if renal impairment is detected, a different antidiabetic agent may be indicated. To evaluate the effectiveness of therapy, the client's glucose value must be monitored regularly. The prescriber must be notified if the glucose value increases, despite therapy.

5. The nurse teaches a client about heat and cold treatments to manage arthritis pain. Which of the following client statements indicates that the client still has a knowledge deficit?. 1. "I can use heat and cold as often as I want." 2. "With heat, I should apply it for no longer than 20 minutes at a time." 3. "Heat-producing liniments can be used with other heat devices." 4. "Ten to fifteen minutes per application is the maximum time for cold applications."

3. Heat-producing liniment can produce a burn if used with other heat devices that could intensify the heat reaction. Heat and cold can be used as often as the client desires. However, each application of heat should not exceed 20 minutes, and each application of cold should not exceed 10 to 15 minutes. Application for longer periods results in the opposite of the intended effect: vasoconstriction instead of vasodilation with heat, and vasodilation instead of vasoconstriction with cold.

1. On a visit to the clinic, a client reports the onset of early symptoms of rheumatoid arthritis. The nurse should conduct a focused assessment for:. 1. Limited motion of joints. 2. Deformed joints of the hands. 3. Early morning stiffness. 4. Rheumatoid nodules.

3. Initially, most clients with early symptoms of rheumatoid arthritis report early morning stiffness or stiffness after sitting still for a while. Later symptoms of rheumatoid arthritis include limited joint range of motion; deformed joints, especially of the hand; and rheumatoid nodules.

51. Angiotensin-converting enzyme (ACE) inhibitors may be prescribed for the client with diabetes mellitus to reduce vascular changes and possibly prevent or delay development of: 1. Chronic obstructive pulmonary disease (COPD). 2. Pancreatic cancer. 3. Renal failure. 4. Cerebrovascular accident.

3. Renal failure frequently results from the vascular changes associated with diabetes mellitus. ACE inhibitors increase renal blood flow and are effective in decreasing diabetic nephropathy. Chronic obstructive pulmonary disease is not a complication of diabetes, nor is it prevented by ACE inhibitors. Pancreatic cancer is neither prevented by ACE inhibitors nor considered a complication of diabetes. Cerebrovascular accident is not directly prevented by ACE inhibitors, although management of hypertension will decrease vascular disease.

42. Which of the following conditions is the most significant risk factor for the development of type 2 diabetes mellitus? 1. Cigarette smoking. 2. High-cholesterol diet. 3. Obesity. 4. Hypertension.

3. The most important factor predisposing to the development of type 2 diabetes mellitus is obesity. Insulin resistance increases with obesity. Cigarette smoking is not a predisposing factor, but it is a risk factor that increases complications of diabetes mellitus. A high-cholesterol diet does not necessarily predispose to diabetes mellitus, but it may contribute to obesity and hyperlipidemia. Hypertension is not a predisposing factor, but it is a risk factor for developing complications of diabetes mellitus.

The client diagnosed with type 1 diabetes has a glycosylated hemoglobin (A1c) of 8.1%. Which interpretation should the nurse make based on this result? 1. This result is below normal levels. 2. This result is within acceptable levels. 3. This result is above recommended levels. 4. This result is dangerously high.

3. This result is above recommended levels.

The client diagnosed with HHNS was admitted yesterday with a blood glucose level of 780 mg/ dL. The client's blood glucose level is now 300 mg/dL. Which intervention should the nurse implement? 1. Increase the regular insulin IV drip. 2. Check the client's urine for ketones. 3. Provide the client with a therapeutic diabetic meal. 4. Notify the HCP to obtain an order to decrease insulin.

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The nurse is discussing exercising with a client diagnosed with type 2 diabetes whose diabetes is well controlled with diet and exercise. Which information should the nurse include in the teaching about diabetes? 1. Eat a simple carbohydrate snack before exercising. 2. Carry peanut butter crackers when exercising. 3. Encourage the client to walk 20 minutes three (3) times a week. 4. Perform warm-up and cool-down exercises.

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41. The nurse should caution the client with diabetes mellitus who is taking a sulfonylurea that alcoholic beverages should be avoided while taking these drugs because they can cause which of the following? 1. Hypokalemia. 2. Hyperkalemia. 3. Hypocalcemia. 4. Disulfiram (Antabuse)-like symptoms.

4. A client with diabetes who takes any first- or second-generation sulfonylurea should be advised to avoid alcohol intake. Sulfonylureas in combination with alcohol can cause serious disulfiram (Antabuse)-like reactions, including flushing, angina, palpitations, and vertigo. Serious reactions, such as seizures and possibly death, may also occur. Hypokalemia, hyperkalemia, and hypocalcemia do not result from taking sulfonylureas in combination with alcohol.

8. After teaching the client with rheumatoid arthritis about measures to conserve energy in activities of daily living involving the small joints, which of the following, if stated by the client, would indicate the need for additional teaching?. 1. Pushing with palms when rising from a chair. 2. Holding packages close to the body. 3. Sliding objects. 4. Carrying a laundry basket with clinched fingers and fists.

4. Carrying a laundry basket with clinched fingers and fists is not an example of conserving energy of small joints. The laundry basket should be held with both hands opened as wide as possible and with outstretched arms so that pressure is not placed on the small joints of the fingers. When rising from a chair, the palms should be used instead of the fingers so as to distribute weight over the larger area of the palms. Holding packages close to the body provides greater support to the shoulder, elbow, and wrist joints because muscles of the arms and hands are used to stabilize the weight against the body. This decreases the stress and weight or pull on small joints such as the fingers. Objects can be slid with the palm of the hand, which distributes weight over the larger area of the palms instead of stressing the small joints of the fingers to pick up the weight of the object to move it to another place.

34. The client with diabetes mellitus says, "If I could just avoid what you call carbohydrates in my diet, I guess I would be okay." The nurse should base the response to this comment on the knowledge that diabetes affects metabolism of which of the following? 1. Carbohydrates only. 2. Fats and carbohydrates only. 3. Protein and carbohydrates only. 4. Proteins, fats, and carbohydrates.

4. Diabetes mellitus is a multifactorial, systemic disease associated with problems in the metabolism of all food types. The client's diet should contain appropriate amounts of all three nutrients, plus adequate minerals and vitamins.

45. Assessment of the diabetic client for common complications should include examination of the: 1. Abdomen. 2. Lymph glands. 3. Pharynx. 4. Eyes.

4. Diabetic retinopathy, cataracts, and glaucoma are common complications in diabetics, necessitating eye assessment and examination. The feet should also be examined at each client encounter, monitoring for thickening, fissures, or breaks in the skin; ulcers; and thickened nails. Although assessments of the abdomen, pharynx, and lymph glands are included in a thorough examination, they are not pertinent to common diabetic complications

7. The teaching plan for the client with rheumatoid arthritis includes rest promotion. Which of the following would the nurse expect to instruct the client to avoid during rest periods?. 1. Proper body alignment. 2. Elevating the part. 3. Prone lying positions. 4. Positions of flexion.

4. Positions of flexion should be avoided to prevent loss of functional ability of affected joints. Proper body alignment during rest periods is encouraged to maintain correct muscle and joint placement. Lying in the prone position is encouraged to avoid further curvature of the spine and internal rotation of the shoulders.

38. The nurse is administering the initial dose of a rapid-acting insulin to a client with type 1 diabetes. The nurse should assess the client for hypoglycemia within: 1. 0.5 hours. 2. 1 hour. 3. 2 hours. 4. 3 hours.

4. Rapid-acting insulin has an onset in 15 minutes, peaks at 1 hour, and lasts for 3 to 4 hours. Rapid-acting insulin is administered right before or right after a meal. The nurse should assess the client for hypoglycemia 1 hour following administration of the drug.

11. A client with rheumatoid arthritis tells the nurse, "I know it is important to exercise my joints so that I won't lose mobility, but my joints are so stiff and painful that exercising is difficult." Which of the following responses by the nurse would be most appropriate?. 1. "You are probably exercising too much. Decrease your exercise to every other day." 2. "Tell the physician about your symptoms. Maybe your analgesic medication can be increased." 3. "Stiffness and pain are part of the disease. Learn to cope by focusing on activities you enjoy." 4. "Take a warm tub bath or shower before exercising. This may help with your discomfort."

4. Superficial heat applications, such as tub baths, showers, and warm compresses, can be helpful in relieving pain and stiffness. Exercises can be performed more comfortably and more effectively after heat applications. The client with rheumatoid arthritis must balance rest with exercise every day, not every other day. Typically, large doses of analgesics, which can lead to hepatotoxic effects, are not necessary. Learning to cope with the pain by refocusing is inappropriate.

46. The client with type 1 diabetes mellitus is taught to take isophane insulin suspension NPH (Humulin N) at 5 PM each day. The client should be instructed that the greatest risk of hypoglycemia will occur at about what time? 1. 11 AM, shortly before lunch. 2. 1 PM, shortly after lunch. 3. 6 PM, shortly after dinner. 4. 1 AM, while sleeping.

4. The client with diabetes mellitus who is taking NPH insulin (Humulin N) in the evening is most likely to become hypoglycemic shortly after midnight because this insulin peaks in 6 to 8 hours. The client should eat a bedtime snack to help prevent hypoglycemia while sleeping

6. The client with rheumatoid arthritis tells the nurse, "I have a friend who took gold shots and had a wonderful response. Why didn't my physician let me try that?" Which of the following responses by the nurse would be most appropriate?. 1. "It's the physician's prerogative to decide how to treat you. The physician has chosen what is best for your situation." 2. "Tell me more about your friend's arthritic condition. Maybe I can answer that question for you." 3. "That drug is used for cases that are worse than yours. It wouldn't help you, so don't worry about it." 4. "Every person is different. What works for one client may not always be effective for another."

4. The nurse's most appropriate response is one that is therapeutic. The basic principle of therapeutic communication and a therapeutic relationship is honesty. Therefore, the nurse needs to explain truthfully that each client is different and that there are various forms of arthritis and arthritis treatment. To state that it is the physician's prerogative to decide how to treat the client implies that the client is not a member of his or her own health care team and is not a participant in his or her care. The statement also is defensive, which serves to block any further communication or questions from the client about the physician. Asking the client to tell more about the friend presumes that the client knows correct and complete information, which is not a valid assumption to make. The nurse does not know about the client's friend and should not make statements about another client's condition. Stating that the drug is for cases that are worse than the client's demonstrates that the nurse is making assumptions that are not necessarily valid or appropriate. Also, telling the client not to worry ignores the underlying emotions associated with the question, totally discounting the client's feelings.

Which arterial blood gas results should the nurse expect in the client diagnosed with diabetic ketoacidosis? 1. pH 7.34, Pao2 99, Paco2 48, HCO3 24. 2. pH 7.38, Pao2 95, Paco2 40, HCO3 22. 3. pH 7.46, Pao2 85, Paco2 30, HCO3 26. 4. pH 7.30, Pao2 90, Paco2 30, HCO3 18.

4. This ABG indicates metabolic acidosis, which is expected in a client diagnosed with diabetic ketoacidosis.

The physician prescribes continuous IV nitroglycerin infusion for the client with myocardial infarction. The nurse should: 1. Obtain an infusion pump for the medication. 2. Take the blood pressure every 4 hours. 3. Monitor urine output hourly. 4. Obtain serum potassium levels daily.

1. IV nitroglycerin infusion requires an infusion pump for precise control of the medication. Blood pressure monitoring would be done with a continuous system, and more frequently than every 4 hours. Hourly urine outputs are not always required. Obtaining serum potassium levels is not associated with nitroglycerin infusion.

Which of the following symptoms should the nurse teach the client with unstable angina to report immediately to the physician? 1. A change in the pattern of the chest pain. 2. Pain during sexual activity. 3. Pain during an argument. 4. Pain during or after a physical activity.

1.

A nurse receives a serum laboratory report for six different clients with admitting diagnoses of chest pain. After reviewing all of the lab reports, in which order should the nurse address each lab value? Prioritize the order in which the nurse should address each of the clients' results. ______ Troponin T 42 ng/mL (0.0-0.4 ng/mL) ______ WBC 11,000 K/μL ______ Hgb 7.2 g/dL ______ SCr 2.2 mg/dL ______ K 2.2 mEq/L ______ Total cholesterol 430 mg/dL

(1) Troponin T 42 ng/mL (0.0-0.4 ng/mL) (6) WBC 11,000 K/μL (3) Hgb 7.2 g/dL (4) SCr 2.2 mg/dL (2) K 2.2 mEq/L (5) Total cholesterol 430 mg/dL Rationale: The nurse should address the elevated troponin level first. Cardio- specific troponins (troponin T, cTnT, and troponin I, cTnI) are re- leased into circulation after myocardial injury and are highly specific indicators of myocardial infarction. Since "time is muscle," the client needs to be treated immediately to prevent extension of the infarct and possible death. The nurse should address the decreased serum potas- sium level (K) second. The normal serum K level is 3.5 to 5.8 mEq/L. A low serum K level can cause life-threatening dysrhythmias. The normal hemoglobin (Hgb) is 13.1 to 17.1 g/dL. A low Hgb can con- tribute to inadequate tissue perfusion and contribute to myocardial ischemia. The normal serum creatinine (SCr) is 0.4 to 1.4 mg/dL. Impaired circulation may be causing this alteration and further client assessment is needed. Medication doses may need to be adjusted with impaired renal perfusion. The normal total serum cholesterol should be less than 200 mg/dL. This is a risk factor for development of coronary artery disease. The client needs teaching. The normal white blood cell (WBC) count is 3.9 to 11.9 K/μL. Because the finding is normal, it can be addressed last

A nurse working on a telemetry unit is planning to complete noon assessments for four assigned clients with type 1 diabetes mellitus. All of the clients received subcutaneous insulin aspart (NovoLog®) at 0800 hours. In which order should the nurse assess the clients? Place each answer option into the correct order. _____ A 60-year-old client who is nauseous and has just vomited for the second time _____ A 45-year-old client who is dyspneic and has chest pressure and new onset atrial fibrillation _____ A 75-year-old client with a fingerstick blood glucose level of 300 mg/dL _____ A 50-year-old client with a fingerstick blood glucose level of 70 mg/dL

(2) A 60-year-old client who is nauseous and has just vomited for the second time (1) A 45-year-old client who is dyspneic and has chest pressure and new onset atrial fibrillation (3) A 75-year-old client with a fingerstick blood glucose level of 300 mg/dL (4) A 50-year-old client with a fingerstick blood glucose level of 70 mg/dL Rationale: First, the nurse should assess the client with new onset atrial fibrillation and dyspnea. Diabetes increases the risk of coronary artery disease and myocardial infarction. Next, assess the client who just vomited. The client with a 300 mg/dL blood glucose level should then be assessed. This blood glucose level is not immediately life-threatening, but needs to be lowered as soon as possible. The client with the blood glucose level of 70 mg/dL can be assessed last because this is a normal blood glucose level. ➧ Test-taking Tip: Use the ABC's (airway, breathing, circulation) to establish the priority client.Then, look at the information provided for each client to determine the next priority.

A nurse who is beginning a shift on a cardiac step- down unit receives shift report for four clients. In which order should the nurse assess the clients? Prioritize the nurse's actions by placing each client in order from most urgent (1) to least urgent (4). ______ A 56-year-old client who was admitted 1 day ago with chest pain receiving intravenous (IV) heparin and has a partial thromboplastin time (PTT) due back in 30 minutes ______ A 62-year-old client with end-stage cardiomyopathy, blood pressure (BP) of 78/50 mm Hg, 20 mL/hr urine output, and a "Do Not Resuscitate" order and whose family has just arrived ______ A 72-year-old client who was transferred 2 hours ago from the intensive care unit (ICU) following a coronary artery bypass graft and has new onset atrial fibrillation with rapid ventricular response ______ A 38-year-old postoperative client who had an aortic valve replacement 2 days ago, BP 114/72 mm Hg, heart rate (HR) 100 beats/min, respiratory rate (RR) 28 breaths/min, and temperature 101.2°F (38.4°C)

(3) A 56-year-old client who was admitted 1 day ago with chest pain receiving intravenous (IV) heparin and has a partial thromboplastin time (PTT) due back in 30 minutes (4) A 62-year-old client with end-stage cardiomyopathy, blood pressure (BP) of 78/50 mm Hg, 20 mL/hr urine output, and a "Do Not Resuscitate" order and whose family has just arrived (1) A 72-year-old client who was transferred 2 hours ago from the intensive care unit (ICU) following a coronary artery bypass graft and has new onset atrial fibrillation with rapid ventricular response (2) A 38-year-old postoperative client who had an aortic valve replacement 2 days ago, BP 114/72 mm Hg, heart rate (HR) 100 beats/min, respiratory rate (RR) 28 breaths/min, and temperature 101.2°F (38.4°C) Rationale: The client with new onset atrial fibrillation should be assessed first because it is the most life threatening. The postoperative client with the elevated temperature should be assessed next because the elevated temperature, RR, and HR increase the demands on the heart and could be a sign of pulmonary complications. Third, the nurse should assess the client with the heparin infusion. PTT results should be back, and the dose may require adjustment. Last, the client with end-stage cardiomyopathy should be assessed. The family will have had time alone with the client, and the client and family may need emotional support. ➧ Test-taking Tip: When establishing priorities, first determine life-threatening situations and then prioritize remaining clients by using the ABCs (airway, breathing, and circulation). Recall from Maslow's Hierarchy of Needs that physiological problems are priority over psychosocial issues, thus the client with end- stage cardiomyopathy should be assessed last.

A client taking thyroid replacement hormone was in- volved in an automobile accident in another state and was hospitalized for a femur fracture. The physician did not prescribe replacement hormone because the client's medication history was unknown and the client was a poor historian at the time of the accident due to pain. A week after being hospitalized, a nurse notes that the client is becoming increasingly lethar- gic. Vital signs show a decreased blood pressure, res- piratory rate, temperature, and pulse. Which actions should be taken by the nurse? Place each nursing action in the order of priority. ____ Warm the client ____ Administer intravenous fluids ____ Assist in ventilatory support ____ Administer the prescribed thyroxine

(3) Warm the client (2) Administer intravenous fluids (1) Assist in ventilatory support (4) Administer the prescribed thyroxine Rationale: The client is experiencing myxedema coma. The initial action is to maintain a patent airway and administer oxygen. Fluid would be replaced next because of hypotension. The client should be warmed to prevent an increase in metabolic demand. Finally, thyroxine would be administered cautiously because the decreased metabolic rate and atherosclerosis of myxedema may result in angina. ➧ Test-taking Tip: Use the ABCs (airway, breathing, circulation) to establish priority and then the remaining actions.

After the administration of t-PA, the nurse should: 1. Observe the client for chest pain. 2. Monitor for fever. 3. Review the 12-lead electrocardiogram (ECG). 4. Auscultate breath sounds.

1. Although monitoring the 12-lead ECG and monitoring breath sounds are important, observing the client for chest pain is the nursing assessment priority because closure of the previously obstructed coronary artery may recur. Clients who receive t-PA frequently receive heparin to prevent closure of the artery after administration of t-PA. Careful assessment for signs of bleeding and monitoring of partial thromboplastin time are essential to detect complications. Administration of t-PA should not cause fever.

A 60-year-old comes into the emergency department with crushing substernal chest pain that radiates to the shoulder and left arm. The admitting diagnosis is acute myocardial infarction (MI). Admission prescriptions include oxygen by nasal cannula at 4 L/min, complete blood count (CBC), a chest radiograph, a 12-lead electrocardiogram (ECG), and 2 mg of morphine sulfate given IV. The nurse should first: 1. Administer the morphine. 2. Obtain a 12-lead ECG. 3. Obtain the blood work. 4. Prescribe the chest radiograph.

1. Although obtaining the ECG, chest radiograph, and blood work are all important, the nurse's priority action should be to relieve the crushing chest pain. Therefore, administering morphine sulfate is the priority action.

The client has been managing angina episodes with nitroglycerin. Which of the following indicate the drug is effective? 1. Decreased chest pain. 2. Increased blood pressure. 3. Decreased blood pressure. 4. Decreased heart rate.

1 Nitroglycerin acts to decrease myocardial oxygen consumption. Vasodilation makes it easier for the heart to eject blood, resulting in decreased oxygen needs. Decreased oxygen demand reduces pain caused by heart muscle not receiving sufficient oxygen. While blood pressure may decrease ever so slightly due to the vasodilation effects of nitroglycerine, it is only secondary and not related to the angina the patient is experiencing. Increased blood pressure would mean the heart would work harder, increasing oxygen demand and thus angina. Decreased heart rate is not an effect of nitroglycerine.

A client has a throbbing headache when nitroglycerin is taken for angina. The nurse should instruct the client that: 1. Acetaminophen (Tylenol) or Ibuprofen (Advil) can be taken for this common side effect. 2. Nitroglycerin should be avoided if the client is experiencing this serious side effect. 3. Taking the nitroglycerin with a few glasses of water will reduce the problem. 4. The client should lie in a supine position to alleviate the headache.

1. Headache is a common side effect of nitro-glycerin that can be alleviated with aspirin, acetaminophen or ibuprofen. The sublingual nitroglycerin needs to be absorbed in the mouth, which will be disrupted with drinking. Lying fl at will increase blood flow to the head and may increase pain and exacerbate other symptoms, such as shortness of breath.

A client is admitted with a myocardial infarction and atrial fibrillation. While auscultating the heart, the nurse notes an irregular heart rate and hears an extra heart sound at the apex after the S2 that remains constant throughout the respiratory cycle. The nurse should document these findings as: 1. Heart rate irregular with S3. 2. Heart rate irregular with S4. 3. Heart rate irregular with aortic regurgitation. 4. Heart rate irregular with mitral stenosis.

1. An S3 heart sound occurs early in diastole as the mitral and tricuspid valves open and blood rushes into the ventricles. To distinguish an S3 from a physiologic S2 split, a split S2 occurs during inspiration and S3 remains constant during the respiratory cycle. Its pitch is softer and best heard with the bell at the apex, and it is one of the first clinical findings in left ventricular failure. An S4 is heard in late diastole when atrial contraction pumps volume into a stiff, noncompliant ventricle. An S4 is not heard in a client with atrial fibrillation because there is no atrial contraction. Murmurs are sounds created by turbulent blood flow through an incompetent or stenotic valve.

A clinic nurse is teaching a client who has been diag- nosed with hypothyroidism. Which instructions should the nurse provide regarding the use of levothyroxine sodium (Synthroid®)? SELECT ALL THAT APPLY. 1. Take the medication 1 hour before or 2 hours after breakfast. 2. Obtain a pulse rate before taking the medication, and call the clinic if the pulse rate is greater than 100 beats per minute. 3. Report adverse effects of the medication, including weight gain, cold intolerance, and alopecia. 4. Use levothyroxine sodium (Synthroid®) as a replacement hormone for diminished or absent thyroid function. 5. Have frequent laboratory monitoring to be sure your levels of T3 and T4 decrease.

1, 2, 4 Taking the medication on an empty stomach promotes regular absorp- tion. It should be taken in the morning to mimic normal hormone release and prevent insomnia. During initial dosage adjustment, tachycardia could indicate a dose that is too high. The replacement hormone is used in primary or secondary atrophy of the gland, after thyroidectomy, after excessive thyroid radiation, after the administration of antithyroid medications, or in congenital thyroid defects. Weight gain and cold intolerance could indicate that the dose is too low. Alopecia may indicate that the dose is too high. T3 and T4 should rise with treatment.

22. A nurse is participating in a diabetes screening program. Who of the following is (are) at risk for developing type 2 diabetes? Select all that apply. 1. A 32-year-old female who delivered a 91⁄2-lb (4,309-g) infant. 2. A 44-year-old Native American (First Nations) who has a body mass index (BMI) of 32. 3. An 18-year-old immigrant from Mexico who jogs four times a week. 4. A 55-year-old Asian who has hypertension and two siblings with type 2 diabetes. 5. A 12-year-old who is overweight.

1, 2, 4, 5 The risk factors for developing type 2 diabetes include giving birth to an infant weighing more than 9 lb (4,082 g); obesity (BMI over 30); ethnicity of Asian, African, Native American, or First Nations; age greater than 45 years; hypertension; and family history in parents or siblings. Childhood obesity is also a risk factor for type 2 diabetes. Maintaining an ideal weight, eating a low-fat diet, and exercising regularly decrease the risk of type 2 diabetes.

When monitoring a client who is receiving tissue plasminogen activator (t-PA), the nurse should have resuscitation equipment available because reperfusion of the cardiac tissue can result in which of the following? 1. Cardiac arrhythmias. 2. Hypertension. 3. Seizure. 4. Hypothermia.

1. Cardiac arrhythmias are commonly observed with administration of t-PA. Cardiac arrhythmias are associated with reperfusion of the cardiac tissue. Hypotension is commonly observed with administra-tion of t-PA. Seizures and hypothermia are not gener-ally associated with reperfusion of the cardiac tissue.

A 68-year-old client on day 2 after hip surgery has no cardiac history but reports having chest heaviness. The first nursing action should be to: 1. Inquire about the onset, duration, severity, and precipitating factors of the heaviness. 2. Administer oxygen via nasal cannula. 3. Offer pain medication for the chest heaviness. 4. Inform the physician of the chest heaviness.

1. Further assessment is needed in this situation. It is premature to initiate other actions until further data have been gathered. Inquiring about the onset, duration, location, severity, and precipitating factors of the chest heaviness will provide pertinent information to convey to the physician.

A client with acute chest pain is receiving IV morphine sulfate. Which of the following results are intended effects of morphine? Select all that apply. 1. Reduces myocardial oxygen consumption. 2. Promotes reduction in respiratory rate. 3. Prevents ventricular remodeling. 4. Reduces blood pressure and heart rate. 5. Reduces anxiety and fear.

1, 4, 5 Morphine sulfate acts as an analgesic and sedative. It also reduces myocardial oxygen consumption, blood pressure, and heart rate. Morphine also reduces anxiety and fear due to its sedative effects and by slowing the heart rate. It can depress respirations; however, such an effect may lead to hypoxia, which should be avoided in the treatment of chest pain. Angiotensin-converting enzyme-inhibitor drugs, not morphine, may help to prevent ventricular remodeling.

The nurse is caring for a client who recently experienced a myocardial infarction and has been started on clopidogrel (Plavix). The nurse should develop a teaching plan that includes which of the following points? Select all that apply. 1. The client should report unexpected bleeding or bleeding that lasts a long time. 2. The client should take Plavix with food. 3. The client may bruise more easily and may experience bleeding gums. 4. Plavix works by preventing platelets from sticking together and forming a clot. 5. The client should drink a glass of water after taking Plavix.

1,3,4 Plavix is generally well absorbed and may be taken with or without food; it should be taken at the same time every day and, while food may help prevent potential GI upset, food has no effect on absorption of the drug. Bleeding is the most common adverse effect of Plavix; the client must understand the importance of reporting any unexpected, prolonged, or excessive bleeding including blood in urine or stool. Increased bruising and bleeding gums are possible side effects of Plavix; the client should be aware of this possibility. Plavix is an antiplatelet agent used to prevent clot formation in clients that have experienced or are at risk for myocardial infarction, ischemic stroke, peripheral artery disease, or acute coronary syndrome. It is not necessary to drink a glass of water after taking Plavix.

An older adult has chest pain and shortness of breath. The health care provider prescribes nitroglycerin tablets. What should the nurse instruct the client to do? 1. Put the tablet under the tongue until it is absorbed. 2. Swallow the tablet with 120 mL of water. 3. Chew the tablet until it is dissolved. 4. Place the tablet between the cheek and gums until it disappears.

1. The client is having symptoms of a myocardial infarction. The first action is to prevent platelet formation and block prostaglandin synthesis. The client should place the tablet under the tongue and wait until it is absorbed. Nitroglycerin tablets are not effective if chewed, swallowed, or placed between the cheek and gums.

4. Propylthiouracil (PTU) is prescribed for a client with Graves' disease. The nurse should teach the client to immediately report which of the following? 1. Sore throat. 2. Painful, excessive menstruation. 3. Constipation. 4. Increased urine output.

1. The most serious adverse effects of PTU are leukopenia and agranulocytosis, which usually occur within the first 3 months of treatment. The client should be taught to promptly report to the health care provider signs and symptoms of infection, such as a sore throat and fever. Clients having a sore throat and fever should have an immediate white blood cell count and differential performed, and the drug must be withheld until the results are obtained. Painful menstruation, constipation, and increased urine output are not associated with PTU therapy.

The nurse is caring for a client diagnosed with an anterior myocardial infarction 2 days ago. Upon assessment, the nurse identifies a systolic murmur at the apex. The nurse should first: 1. Assess for changes in vital signs. 2. Draw an arterial blood gas. 3. Evaluate heart sounds with the client leaning forward. 4. Obtain a 12-lead electrocardiogram.

1. The nurse should first obtain vital signs as changes in the vital signs will reflect the severity of the sudden drop in cardiac output: decrease in blood pressure, increase in heart rate, and increase in respirations. Infarction of the papillary muscles is a potential complication of an MI causing ineffective closure of the mitral valve during systole. Mitral regurgitation results when the left ventricle contracts and blood flows backward into the left atrium, which is heard at the fifth intercostal space, left midclavicular line. The murmur worsens during expiration and in the supine or left-side position and can best be heard when the client is in these positions, not with the client leaning forward. A 12-lead ECG views the electrical activity of the heart; an echocardiogram views valve function.

The nurse notices that a client's heart rate decreases from 63 to 50 bpm on the monitor. The nurse should first: 1. Administer atropine 0.5 mg IV push. 2. Auscultate for abnormal heart sounds. 3. Prepare for transcutaneous pacing. 4. Take the client's blood pressure.

4. The nurse should first assess the client's tolerance to the drop in heart rate by checking the blood pressure and level of consciousness and determine if Atropine is needed. If the client is symptomatic, Atropine and transcutaneous pacing are interventions for symptomatic bradycardia. Once the client is stable, further physical assessments can be done.

25. A client with type 1 diabetes mellitus has diabetic ketoacidosis. Which of the following findings has the greatest effect on fluid loss? 1. Hypotension. 2. Decreased serum potassium level. 3. Rapid, deep respirations. 4. Warm, dry skin.

3. Due to the rapid, deep respirations, the client is losing fluid from vaporization from the lungs and skin (insensible fluid loss). Normally, about 900 mL of fluid is lost per day through vaporization. Decreased serum potassium level has no effect on insensible fluid loss. Hypotension occurs due to polyuria and inadequate fluid intake. It may decrease the flow of blood to the skin, causing the skin to be warm and dry.

21. The nurse is obtaining a health history from a client with diabetes mellitus who has been taking insulin for many years. Currently the client reports having periods of hypoglycemia followed by periods of hyperglycemia. The nurse should specifically ask if the client is 1. Eating snacks between meals. 2. Initiating the use of the insulin pump. 3. Injecting insulin at a site of lipodystrophy. 4. Adjusting insulin according to blood glucose levels.

3. Lipodystrophy, specifically lipohypertrophy, involves swelling of the fat at the site of repeated injections, which can interfere with the absorption of insulin, resulting in erratic blood glucose levels. Because the client has been receiving insulin for many years, this is the most likely cause of poor control. Eating snacks between meals causes hyperglycemia. Adjusting insulin according to blood glucose levels would not cause hypoglycemia but normal levels. Initiating an insulin pump would not, of itself, cause the periods of hyperglycemia.

Which of the following is the most appropriate diet for a client during the acute phase of myocardial infarction? 1. Liquids as desired. 2. Small, easily digested meals. 3. Three regular meals per day. 4. Nothing by mouth.

2 Recommended dietary principles in the acute phase of MI include avoiding large meals because small, easily digested foods are better tolerated. Fluids are given according to the client's needs, and sodium restrictions may be prescribed, especially for clients with manifestations of heart failure. Cholesterol restrictions may be prescribed as well. Clients are not prescribed diets of liquids only or restricted to nothing by mouth unless their condition is very unstable.

The client who experiences angina has been told to follow a low-cholesterol diet. Which of the following meals would be best? 1. Hamburger, salad, and milkshake. 2. Baked liver, green beans, and coffee. 3. Spaghetti with tomato sauce, salad, and coffee. 4. Fried chicken, green beans, and skim milk.

3. Pasta, tomato sauce, salad, and coffee would be the best selection for the client following a low-cholesterol diet. Hamburgers, milkshakes, liver, and fried foods tend to be high in cholesterol.

A clinic nurse evaluates that a client's levothyroxine (Synthroid®) dose is too low when which findings are noted? SELECT ALL THAT APPLY. 1. Increased appetite 2. Decreased sweating 3. Apathy and fatigue 4. Paresthesias 5. Fine tremor of fingers and tongue 6. Slowed mental processes

2, 3, 4, 6 Levothyroxine is used in treating hypothyroidism. Symptoms of hypothyroidism appear if the dose is too low and include decreased sweating, apathy and fatigue, paresthesias, and slowed mental processes. Increased appetite and fine tremors are signs of hyperthy- roidism and can indicate the dose is too high. ➧ Test-taking Tip: Recall that hypothyroidism is characterized by a slowing of body processes. Eliminate options 1 and 5 because these reflect increased sympathetic stimulation.

3. A 34-year-old female is diagnosed with hypothyroidism. The nurse should assess the client for which of the following? Select all that apply. 1. Rapid pulse. 2. Decreased energy and fatigue. 3. Weight gain of 10 lb (4.5 kg). 4. Fine, thin hair with hair loss. 5. Constipation. 6. Menorrhagia.

2, 3, 5, 6. Clients with hypothyroidism exhibit symptoms indicating a lack of thyroid hormone. Bradycardia, decreased energy and lethargy, memory problems, weight gain, coarse hair, constipation, and menorrhagia are common signs and symptoms of hypothyroidism.

A nurse is working with a certified nursing assistant (CNA) providing care for four clients on a busy telemetry unit. All four clients are in need of immedi- ate attention. The CNA is a senior nursing student who has been administering medications and per- forming procedures during clinical experiences as a student nurse. The charge nurse supervising care on the telemetry unit determines that care is appropriate when the registered nurse (RN) working with the CNA delegates: SELECT ALL THAT APPLY. 1. administering acetaminophen (Tylenol®) to the client with an elevated temperature. 2. taking vital signs on the client newly admitted with a diagnosis of heart failure. 3. finishing the discharge instructions so the client with a new pacemaker implant can go home. 4. changing a client's chest tube dressing because it got wet when the water pitcher overturned. 5. providing a sponge bath for the client with the elevated temperature. 6. checking the lung sounds of the client whose chest tube drainage system was tipped over and then righted

2, 5 Legally a student nurse employed as a nursing assistant in a facility is only allowed to perform tasks listed in the job description of a nursing assistant even though the student nurse has received instruction and acquired competence in administering medications and performing sterile procedures. The tasks of a nursing assistant include taking vital signs and bathing clients. Medication administration, teaching, sterile procedures, and assessments are not within the nursing assistant's scope of practice.

The nurse has completed an assessment on a client with a decreased cardiac output. Which findings should receive the highest priority? 1. BP 110/62, atrial fibrillation with HR 82, bibasilar crackles. 2. Confusion, urine output 15 mL over the last 2 hours, orthopnea. 3. SpO2 92 on 2 L nasal cannula, respirations 20, 1+ edema of lower extremities. 4. Weight gain of 1 kg in 3 days, BP 130/80, mild dyspnea with exercise.

2. A low urine output and confusion are signs of decreased tissue perfusion. Orthopnea is a sign of left-sided heart failure. Crackles, edema, and weight gain should be monitored closely, but the levels are not as high a priority. With atrial fibrillation, there is a loss of atrial kick, but the blood pressure and heart rate are stable.

6. The nurse is evaluating a client with hyperthyroidism who is taking Propylthiouracil (PTU) 100 mg/day in three divided doses for maintenance therapy. Which of the following statements from the client indicates the desired outcome of the drug? 1. "I have excess energy throughout the day." 2. "I am able to sleep and rest at night." 3. "I have lost weight since taking this medication." 4. "I do perspire throughout the entire day."

2. A typical sign of thyrotoxicosis is irritability caused by the high levels of circulating thyroid hormones in the body. This symptom decreases as the client responds to therapy. Thyrotoxicosis does not cause confusion. The client may be worried about her illness, and stress may influence her mood; however, irritability is a common symptom of thyrotoxicosis and the client should be informed of that fact rather than blamed.

A client has driven himself to the emergency department. He is 50 years old, has a history of hypertension, and informs the nurse that his father died from a heart attack at age 60. The client has indigestion. The nurse connects him to an electrocardiogram monitor and begins administering oxygen at 2 L/min per nasal cannula. The nurse's next action should be to: 1. Call for the physician. 2. Start an IV infusion. 3. Obtain a portable chest radiograph. 4. Draw blood for laboratory studies.

2. Advanced cardiac life support recommends that at least one or two IV lines be inserted in one or both of the antecubital spaces. Calling the physician, obtaining a portable chest radiograph, and drawing blood for the laboratory are important but secondary to starting the IV line.

The physician refers the client with unstable angina for a cardiac catheterization. The nurse explains to the client that this procedure is being used in this specific situation to: 1. Open and dilate blocked coronary arteries. 2. Assess the extent of arterial blockage. 3. Bypass obstructed vessels. 4. Assess the functional adequacy of the valves and heart muscle.

2. Cardiac catheterization is done in clients with angina primarily to assess the extent and the severity of the coronary artery blockage. A decision about medical management, angioplasty, or coronary artery bypass surgery will be based on the catheterization results. Coronary bypass surgery would be used to bypass obstructed vessels. Although cardiac catheterization can be used to assess the functional adequacy of the valves and heart muscle, in this case the client has unstable angina and therefore would need the procedure to assess the extent of arterial blockage.

1. The nurse is completing a health assessment of a 42-year-old female with suspected Graves' disease. The nurse should assess this client for: 1. Anorexia. 2. Tachycardia. 3. Weight gain. 4. Cold skin.

2. Graves' disease, the most common type of thyrotoxicosis, is a state of hypermetabolism. The increased metabolic rate generates heat and produces tachycardia and fine muscle tremors. Anorexia is associated with hypothyroidism. Loss of weight, despite a good appetite and adequate caloric intake, is a common feature of hyperthyroidism. Cold skin is associated with hypothyroidism.

A client admitted for a myocardial infarction (MI) develops cardiogenic shock. An arterial line is inserted. Which of the following prescriptions from the health care provider should the nurse verify before implementing? 1. Call for urine output less than 30 mL/h for 2 consecutive hours. 2. Metoprolol (Lopressor) 5 mg IV push. 3. Prepare for a pulmonary artery catheter insertion. 4. Titrate dobutamine (Dobutrex) to keep systolic BP greater than 100.

2. Metoprolol is indicated in the treatment of hemodynamically stable clients with an acute MI to reduce cardiovascular mortality. Cardiogenic shock causes severe hemodynamic instability and a beta blocker will further depress myocardial contractility. The metoprolol should be discontinued. The decrease in cardiac output will impair perfusion to the kidneys. Cardiac output, hemodynamic measurements, and appropriate interventions can be determined with a PA catheter. Dobutamine will improve contractility and increase the cardiac output that is depressed in cardiogenic shock.

A client with chest pain is prescribed intravenous nitroglycerin. Which assessment is of greatest concern for the nurse initiating the nitroglycerin drip? 1. Serum potassium is 3.5 mEq/L (3.5 mmol/L). 2. Blood pressure is 88/46. 3. ST elevation is present on the electrocardiogram. 4. Heart rate is 61.

2. Nitroglycerin is a vasodilator that will lower blood pressure. The client is having chest pain and the ST elevation indicates injury to the myocardium, which may benefit from nitroglycerin. The potassium and heart rate are within normal range.

While caring for a client who has sustained a myocardial infarction (MI), the nurse notes eight premature ventricular contractions (PVCs) in 1 minute on the cardiac monitor. The client is receiving an IV infusion of 5% dextrose in water (D5W) and oxygen at 2 L/min. The nurse's first course of action should be to: 1. Increase the IV infusion rate. 2. Notify the physician promptly. 3. Increase the oxygen concentration. 4. Administer a prescribed analgesic.

2. PVCs are often a precursor of life-threatening arrhythmias, including ventricular tachycardia and ventricular fibrillation. An occasional PVC is not considered dangerous, but if PVCs occur at a rate greater than five or six per minute in the post-MI client, the physician should be notified immediately. More than six PVCs per minute is considered serious and usually calls for decreasing ventricular irritability by administering medications such as lidocaine hydrochloride. Increasing the IV infusion rate would not decrease the number of PVCs. Increasing the oxygen concentration should not be the nurse's first course of action; rather, the nurse should notify the physician promptly. Administering a prescribed analgesic would not decrease ventricular irritability.

19. The nurse is instructing the client with hypothyroidism who takes levothyroxine (Synthroid) 100 mcg, digoxin (Lanoxin) and simvastatin (Zocor). Teaching regarding medications is effective if the client will take: 1. The Synthroid with breakfast and the other medications after breakfast. 2. The Synthroid before breakfast and the other medications 4 hours later. 3. All medications together 1 hour after eating breakfast. 4. All medications before going to bed.

2. Synthroid (levothyroxine) must be given at the same time each day on an empty stomach, preferably 1/2 to 1 hour before breakfast. Other medications may impair the action of levothyroxine (Synthroid) absorption; the client should separate doses of other medications by 4 to 5 hours.

14. One day following a subtotal thyroidectomy, a client begins to have tingling in the fingers and toes. The nurse should first: 1. Encourage the client to flex and extend the fingers and toes. 2. Notify the physician. 3. Assess the client for thrombophlebitis. 4. Ask the client to speak.

2. Tetany may occur after thyroidectomy if the parathyroid glands are accidentally injured or removed during surgery. This would cause a disturbance in serum calcium levels. An early sign of tetany is numbness and tingling of the fingers or toes and in the circumoral region. Tetany may occur from 1 to 7 days postoperatively. Late signs and symptoms of tetany include seizures, contraction of the glottis, and respiratory obstruction. The nurse should notify the physician. Exercising the joints in the fingers and toes will not relieve the tetany. The client is not exhibiting signs of thrombophlebitis. There is no indication of nerve damage that would cause the client not to be able to speak.

15. Which of the following medications should be available to provide emergency treatment if a client develops tetany after a subtotal thyroidectomy? 1. Sodium phosphate. 2. Calcium gluconate. 3. Echothiophate iodide. 4. Sodium bicarbonate.

2. The client with tetany is suffering from hypocalcemia, which is treated by administering an IV preparation of calcium, such as calcium gluconate or calcium chloride. Oral calcium is then necessary until normal parathyroid function returns. Sodium phosphate is a laxative. Echothiophate iodide is an eye preparation used as a miotic for an antiglaucoma effect. Sodium bicarbonate is a potent systemic antacid. CN: Pharmacological and parenteral therapies; CL: Apply

When administering a thrombolytic drug to the client who is experiencing a myocardial infarction (MI) and who has premature ventricular contractions, the expected outcome of the drug is to: 1. Promote hydration. 2. Dissolve clots. 3. Prevent kidney failure. 4. Treat dysrhythmias.

2. Thrombolytic drugs are administered within the first 6 hours after onset of an MI to lyse clots and reduce the extent of myocardial damage.

16. A 60-year-old female is diagnosed with hypothyroidism. The nurse should assess the client for which of the following? 1. Tachycardia. 2. Weight gain. 3. Diarrhea. 4. Nausea.

2. Typical signs and symptoms of hypothyroidism include weight gain, fatigue, decreased energy, apathy, brittle nails, dry skin, cold intolerance, hair loss, constipation, and numbness and tingling in the fingers. Tachycardia is a sign of hyperthyroidism, not hypothyroidism. Diarrhea and nausea are not symptoms of hypothyroidism.

If a client displays risk factors for coronary artery disease, such as smoking cigarettes, eating a diet high in saturated fat, or leading a sedentary lifestyle, techniques of behavior modification may be used to help the client change the behavior. The nurse can best reinforce new adaptive behaviors by: 1. Explaining how the risk factor behavior leads to poor health. 2. Withholding praise until the new behavior is well established. 3. Rewarding the client whenever the acceptable behavior is performed. 4. Instilling mild fear into the client to extinguish the behavior.

3 A basic principle of behavior modification is that behavior that is learned and continued is behavior that has been rewarded. Other reinforcement techniques have not been found to be as effective as reward.

20. The nurse is teaching a diabetic client using an empowerment approach. The nurse should initiate teaching by asking which of the following? 1. "How much does your family need to be involved in learning about your condition?" 2. "What is required for your family to manage your symptoms?" 3. "What activities are most important for you to be able to maintain control of your diabetes?" 4. "What do you know about your medications and condition?"

3. Empowerment is an approach to clinical practice that emphasizes helping people discover and use their innate abilities to gain mastery over their own condition. Empowerment means that individuals with a health problem have the tools, such as knowledge, control, resources, and experience, to implement and evaluate their self- management practices. Involvement of others, such as asking the client about family involvement, implies that the others will provide the direct care needed rather than the client. Asking the client what the client needs to know implies that the nurse will be the one to provide the information. Telling the client what is required does not provide the client with options or lead to empowerment.

After a myocardial infarction, the hospitalized client is taught to move the legs while resting in bed. The expected outcome of this exercise is to: 1. Prepare the client for ambulation. 2. Promote urinary and intestinal elimination. 3. Prevent thrombophlebitis and blood clot formation. 4. Decrease the likelihood of pressure ulcer formation.

3 Encouraging the client to move the legs while in bed is a preventive strategy taught to all clients who are hospitalized and on bed rest to promote venous return. The muscular action aids in venous return and prevents venous stasis in the lower extremities. These exercises are not intended to prepare the client for ambulation. These exercises are not associated with promoting urinary and intestinal elimination. These exercises are not performed to decrease the risk of pressure ulcer formation

Following diagnosis of angina pectoris, a client reports being unable to walk up two flights of stairs without pain. Which of the following measures would most likely help the client prevent this problem? 1. Climb the steps early in the day. 2. Rest for at least an hour before climbing the stairs. 3. Take a nitroglycerin tablet before climbing the stairs. 4. Lie down after climbing the stairs.

3 Nitroglycerin may be used prophylactically before stressful physical activities such as stair climbing to help the client remain pain free. Climbing the stairs early in the day would have no impact on decreasing pain episodes. Resting before or after an activity is not as likely to help prevent an activity-related pain episode.

12. Following a subtotal thyroidectomy, the nurse asks the client to speak immediately upon regaining consciousness. The nurse does this to monitor for signs of which of the following? 1. Internal hemorrhage. 2. Decreasing level of consciousness. 3. Laryngeal nerve damage. 4. Upper airway obstruction.

3. Laryngeal nerve damage is a potential complication of thyroid surgery because of the proximity of the thyroid gland to the recurrent laryngeal nerve. Asking the client to speak helps assess for signs of laryngeal nerve damage. Persistent or worsening hoarseness and weak voice are signs of laryngeal nerve damage and should be reported to the physician immediately. Internal hemorrhage is detected by changes in vital signs. The client's level of consciousness can be partially assessed by asking her to speak, but that is not the primary reason for doing so in this situation. Upper airway obstruction is detected by color and respiratory rate and pattern.

As an initial step in treating a client with angina, the physician prescribes nitroglycerin tablets, 0.3 mg given sublingually. This drug's principal effects are produced by: 1. Antispasmodic effects on the pericardium. 2. Causing an increased myocardial oxygen demand. 3. Vasodilation of peripheral vasculature. 4. Improved conductivity in the myocardium.

3 Nitroglycerin produces peripheral vasodilation, which reduces myocardial oxygen consumption and demand. Vasodilation in coronary arteries and collateral vessels may also increase blood flow to the ischemic areas of the heart. Nitroglycerin decreases myocardial oxygen demand. Nitroglycerin does not have an effect on pericardial spasticity or conductivity in the myocardium.

A middle-aged adult with a family history of CAD has the following: total cholesterol 198 (11 mmol/L); LDL cholesterol 120 (6.7 mmol/L); HDL cholesterol 58 (3.2 mmol/L); triglycerides 148 (8.2 mmol/L); blood sugar 102 (5.7 mmol/L); and C-reactive protein (CRP) 4.2. The health care provider prescribes a statin medication and aspirin. The client asks the nurse why these medications are needed. Which is the best response by the nurse? 1. "The labs indicate severe hyperlipidemia and the medications will lower your LDL, along with a low-fat diet." 2. "The triglycerides are elevated and will not return to normal without these medications." 3. "The CRP is elevated indicating inflammation seen in cardiovascular disease, which can be lowered by the medications prescribed." 4. "These medications will reduce the risk of type 2 diabetes."

3. CRP is a marker of inflammation and is elevated in the presence of cardiovascular disease. The high sensitivity CRP (hs-CRP) is the blood test for greater accuracy in measuring the CRP to evaluate cardiovascular risk. The family history, postmenopausal age, LDL above optimum levels, and elevated CRP place the client at risk of CAD. Statin medications can decrease LDL, whereas statins and aspirin can reduce CRP and decrease the risk of MI and stroke. The blood sugar is within normal limits.

9. After treatment with radioactive iodine (RAI) in the form of sodium iodide 131I, the nurse teaches the client to: 1. Monitor for signs and symptoms of hyperthyroidism. 2. Rest for 1 week to prevent complications of the medication. 3. Take thyroxine replacement for the remainder of the client's life. 4. Assess for hypertension and tachycardia resulting from altered thyroid activity.

3. The client needs to be educated about the need for lifelong thyroid hormone replacement. Permanent hypothyroidism is the major complication of RAI 131I treatment. Lifelong medical follow-up and thyroid replacement are warranted. The client needs to monitor for signs and symptoms of hypothyroidism, not hyperthyroidism. Resting for 1 week is not necessary. Hypertension and tachycardia are signs of hyperthyroidism, not hypothyroidism.

7. The nurse should teach the client with Graves' disease to prevent corneal irritation from mild exophthalmos by: 1. Massaging the eyes at regular intervals. 2. Instilling an ophthalmic anesthetic as prescribed. 3. Wearing dark-colored glasses. 4. Covering both eyes with moistened gauze pads.

3. Treatment of mild ophthalmopathy that may accompany thyrotoxicosis includes measures such as wearing sunglasses to protect the eyes from corneal irritation. Treatment of ophthalmopathy should be performed in consultation with an ophthalmologist. Massaging the eyes will not help to protect the cornea. An ophthalmic anesthetic is used to examine and possibly treat a painful eye, not protect the cornea. Covering the eyes with moist gauze pads is not a satisfactory nursing measure to protect the eyes of a client with exophthalmos because treatment is not focused on moisture to the eye but rather on protecting the cornea and optic nerve. In exophthalmos, the retrobulbar connective tissues and extraocular muscle volume are expanded because of fluid retention. The pressure is also increased.

18. When discussing recent onset of feelings of sadness and depression in a client with hypothyroidism, the nurse should inform the client that these feelings are: 1. The effects of thyroid hormone replacement therapy and will diminish over time. 2. Related to thyroid hormone replacement therapy and will not diminish over time. 3. A normal part of having a chronic illness. 4. Most likely related to low thyroid hormone levels and will improve with treatment.

4. Hypothyroidism may contribute to sadness and depression. It is good practice for clients with newly diagnosed depression to be monitored for hypothyroidism by checking serum thyroid hormone and thyroid-stimulating hormone levels. This client needs to know that these feelings may be related to her low thyroid hormone levels and may improve with treatment. Replacement therapy does not cause depression. Depression may accompany chronic illness, but it is not "normal." CN: Psychosocial integrity; CL: Analyze

Alteplase recombinant, or tissue plasminogen activator (t-PA), a thrombolytic enzyme, is administered during the first 6 hours after onset of myocardial infarction (MI) to: 1. Control chest pain. 2. Reduce coronary artery vasospasm. 3. Control the arrhythmias associated with MI. 4. Revascularize the blocked coronary artery.

4 The thrombolytic agent t-PA, administered intravenously, lyses the clot blocking the coronary artery. The drug is most effective when administered within the first 6 hours after onset of MI. The drug does not reduce coronary artery vasospasm; nitrates are used to promote vasodilation. Arrhythmias are managed by antiarrhythmic drugs. Surgical approaches are used to open the coronary artery and re-establish a blood supply to the area.

23. An adult with type 2 diabetes mellitus has been NPO since 10 PM in preparation for having a nephrectomy the next day. At 6 AM on the day of surgery, the nurse reviews the client's chart and laboratory results. Which finding should the nurse report to the physician? 1. Urine output of 350 mL in 8 hours. 2. Urine specific gravity of 1.015. 3. Potassium of 4.0 mEq (4 mmol/L). 4. Blood glucose of 140 mg/dL (7.8 mmol/L).

4 The client's blood glucose level is elevated, beyond levels accepted for fasting; normal blood glucose range is 70 to 120 mg/dL (3.9 to 6.7 mmol/L). The specific gravity is within normal range (1.001 to 1.030). Urine output should be 30 to 50 mL/h; thus, 350 mL is a normal urinary output over 8 hours. The potassium level is normal.

A client has chest pain rated at 8 on a 10-point visual analog scale. The 12-lead electrocardiogram reveals ST elevation in the inferior leads and troponin levels are elevated. What is the highest priority for nursing management of this client at this time? 1. Monitor daily weights and urine output. 2. Permit unrestricted visitation by family and friends. 3. Provide client education on medications and diet. 4. Reduce pain and myocardial oxygen demand.

4. Nursing management for a client with a myocardial infarction should focus on pain manage-ment and decreasing myocardial oxygen demand. Fluid status should be closely monitored. Client education should begin once the client is stable and amenable to teaching. Visitation should be based on client comfort and maintaining a calm environment.

8. A client with Graves' disease is treated with radioactive iodine (RAI) in the form of sodium iodide 131I. Which of the following statements by the nurse will explain to the client how the drug works? 1. "The RAI stabilizes the thyroid hormone levels before a thyroidectomy." 2. "The RAI reduces uptake of thyroxine and thereby improves your condition." 3. "The RAI lowers the levels of thyroid hormones by slowing your body's production of them." 4. "The RAI destroys thyroid tissue so that thyroid hormones are no longer produced."

4. Sodium iodide 131I destroys the thyroid follicular cells, and thyroid hormones are no longer produced. RAI is commonly recommended for clients with Graves' disease, especially the elderly. The treatment results in a "medical thyroidectomy." RAI is given in lieu of surgery, not before surgery. RAI does not reduce uptake of thyroxine. The outcome of giving RAI is the destruction of the thyroid follicular cells. It is possible to slow the production of thyroid hormones with RAI.

17. The nurse should assess a client with hypothyroidism for which of the following? 1. Corneal abrasion due to inability to close the eyelids. 2. Weight loss due to hypermetabolism. 3. Fluid loss due to diarrhea. 4. Decreased activity due to fatigue

4. A major problem for the person with hypothyroidism is fatigue. Other signs and symptoms include lethargy, personality changes, generalized edema, impaired memory, slowed speech, cold intolerance, dry skin, muscle weakness, constipation, weight gain, and hair loss. Incomplete closure of the eyelids, hypermetabolism, and diarrhea are associated with hyperthyroidism.

The client is scheduled for a percutaneous transluminal coronary angioplasty (PTCA) to treat angina. Priority goals for the client immediately after PTCA should include: 1. Minimizing dyspnea. 2. Maintaining adequate blood pressure control. 3. Decreasing myocardial contractility. 4. Preventing fluid volume deficit.

4. Because the contrast medium used in PTCA acts as an osmotic diuretic, the client may experience diuresis with resultant fluid volume deficit after the procedure. Additionally, potassium levels must be closely monitored because the client may develop hypokalemia due to the diuresis. Dyspnea would not be anticipated after this procedure. Maintaining adequate blood pressure control should not be a problem after the procedure. Increased myocardial contractility would be a goal, not decreased contractility.

Which of the following is an expected outcome for a client on the second day of hospitalization after a myocardial infarction (MI)? The client: 1. Continues to have severe chest pain. 2. Can identify risk factors for MI. 3. Participates in a cardiac rehabilitation walking program. 4. Can perform personal self-care activities without pain.

4. By day 2 of hospitalization after an MI, clients are expected to be able to perform personal care without chest pain. Severe chest pain should not be present on day 2 after an MI. Day 2 of hospitalization may be too soon for clients to be able to identify risk factors for MI or to begin a walking program; however, the client may be sitting up in a chair as part of the cardiac rehabilitation program.

Crackles heard on lung auscultation indicate which of the following? 1. Cyanosis. 2. Bronchospasm. 3. Airway narrowing. 4. Fluid-filled alveoli.

4. Crackles are auscultated over fluid-filled alveoli. Crackles heard on lung auscultation do not have to be associated with cyanosis. Bronchospasm and airway narrowing generally are associated with wheezing sounds.

13. A client who has undergone a subtotal thyroidectomy is subject to complications in the first 48 hours after surgery. The nurse should obtain and keep at the bedside equipment to: 1. Begin total parenteral nutrition. 2. Start a cutdown infusion. 3. Administer tube feedings. 4. Perform a tracheotomy.

4. Equipment for an emergency tracheotomy should be kept in the room, in case tracheal edema and airway occlusion occur. Laryngeal nerve damage can result in vocal cord spasm and respiratory obstruction. A tracheostomy set, oxygen and suction equipment, and a suture removal set (for respiratory distress from hemorrhage) make up the emergency equipment that should be readily available. Total parenteral nutrition is not anticipated for the client undergoing thyroidectomy. Intravenous infusion via a cutdown is not an expected possible treatment after thyroidectomy. Tube feedings are not anticipated emergency care.

26. A client is to receive glargine insulin in addition to a dose of aspart. When the nurse checks the blood glucose level at the bedside, it is greater than 200 mg/dL (11.1 mmol/L). How should the nurse administer the insulins? 1. Put air into the glargine insulin vial, and then air into the aspart insulin vial, and draw up the correct dose of aspart insulin first. 2. Roll the glargine insulin vial, then roll the aspart insulin vial. Draw up the longer- acting glargine insulin first. 3. Shake both vials of insulin before drawing up each dose in separate insulin syringes. 4. Put air into the glargine insulin vial, and draw up the correct dose in an insulin syringe; then, with a different insulin syringe, put air into the aspart vial and draw up the correct dose.

4. Glargine is a long-acting recombinant human insulin analog. Glargine should not be mixed with any other insulin product. Insulins should not be shaken; instead, if the insulin is cloudy, roll the vial or insulin pen between the palms of the hands.

Which client is at greatest risk for coronary artery disease? 1. A 32-year-old female with mitral valve prolapse who quit smoking 10 years ago. 2. A 43-year-old male with a family history of CAD and cholesterol level of 158 (8.8 mmol/L). 3. A 56-year-old male with an HDL of 60 (3.3 mmol/L) who takes atorvastatin. 4. A 65-year-old female who is obese with an LDL of 188 (10.4 mmol/L).

4. The woman who is 65 years old, is overweight, and has an elevated LDL is at greatest risk. Total cholesterol >200 (11.1 mmol/L), LDL >100 (5.5 mmol/L), HDL <40 (2.2 mmol/L) in men, HDL <50 (2.8 mmol/L) in women, men 45 years and older, women 55 years and older, smoking, and obesity increase the risk of CAD. Atorvastatin reduces LDL and decreases risk of CAD. The combination of postmenopausal, obesity, and high LDL places this client at greatest risk.

A client is receiving an IV infusion of heparin sodium at 1,200 units/h. The dilution is 25,000 units/500 mL. How many milliliters per hour will this client receive? _________________ mL/h.

5. 24 mL/ h First, calculate how many units are in each milliliter of the medication: Next, calculate how many milliliters the client receives per hour:

A client diagnosed with diabetes mellitus is on an insulin infusion drip. The insulin bag indicates there are 100 units of insulin in 1,000 milliliters (mL) of normal saline. Based on the client's blood glucose reading, the client should receive 1.5 units per hour. To ensure that the client receives 1.5 units per hour, the nurse should set the pump at ______ mL/hr.

ANSWER: 15 100 units : 1,000 mL :: 1.5 units : X mL 100X = 1,500 X = 15

At 0730 hours, a nurse receives a verbal order for a cardiac catheterization to be completed on a client at 1400 hours. Which action should the nurse initiate first? 1. Initiate NPO (nothing per mouth) status for the client. 2. Teach the client about the procedure. 3. Start an intravenous (IV) infusion of 0.9% NaCl. 4. Ask the client to sign a consent form.

ANSWER: 1 A cardiac catheterization is an invasive procedure requiring the client to lie still in a supine position. The client is usually sedated with medication, such as midazolam (Versed®), during the procedure. To avoid aspiration, the client should be NPO 6 to 12 hours prior to the procedure. Because of the time element, NPO status should be initiated first and then teaching should occur. A consent form should be signed after the cardiologist has spoken with the client, and then an IV infusion order would be received. ➧ Test-taking Tip: The term "cardiac catheterization" in the stem indicates that this is an invasive procedure that has the potential to cause aspiration from sedation. Use the ABCs (airway, breathing, circulation) to determine which action should be first. Any action that pertains to maintaining a patent airway should be first.

A nurse is caring for a client following a coro- nary artery bypass graft. Which assessment finding in the immediate postoperative period should be most concerning to the nurse? 1. No chest tube output for 1 hour when previously it was copious 2. Client temperature of 99.1°F (37.2°C) 3. Arterial blood gas (ABG) results show pH 7.32; Pco2 48; HCO3 28; Po2 80 4. Urine output of 160 mL in the last 4 hours

ANSWER: 1 A copiously draining chest tube that is no longer draining indicates an obstruction. There is an increased risk for cardiac tamponade or pleu- ral effusion. A slight elevation in temperature could be the effects of rewarming after surgery. This should continue to be monitored, but is not immediately concerning. The ABG results show compensated respiratory acidosis. Though the pH is low and the PCO2 is high, the kidneys are com- pensating by conserving bicarbonate (HCO3). Normal pH is 7.35-7.45, PCO2 32-42 mm Hg, HCO3 20-24 mmol/L, and PO2 75-100 mm Hg. A urine output of 160 mL/4 hr is equivalent to 40 mL/hr; adequate, but it warrants continued monitoring. Less than 30 mL/hr indicates decreased renal function. ➧ Test-taking Tip: The key phrase in the question is "most concerning." Use the process of elimination and eliminate options 3 and 4 because these are normal findings. Of options 1 and 2, determine which option is most concerning.

552. A nurse is evaluating the blood pressure (BP) results for multiple clients with cardiac problems on a telemetry unit. Which BP reading suggests to the nurse that the client's mean arterial pressure (MAP) is abnormal and warrants notifying the physician? 1. 94/60 mm Hg 2. 98/36 mm Hg 3. 110/50 mm Hg 4. 140/78 mm Hg

ANSWER: 2 A MAP of less than 60 mm Hg indicates that there is inadequate per- fusion to organs. The mean arterial pressure is calculated by the sum of the SBP + 2DBP and then divided by 3 [MAP = (SBP + 2DBP)/3]. Thus the MAP of 98/36 mm Hg is (98 + 72)/3 = 170/3 = 56.7. The mean arterial pressure of 94/60 is 71.3. The mean arterial pressure of 110/50 is 70. The mean arterial pressure of 140/78 is 98.7. ➧ Test-taking Tip: Focus on the issue of the question, a BP reading with a MAP of less than 60.Though a BP of 94/60 mm Hg and 140/78 mm Hg may warrant notifying the physician, the question is asking for a BP with an abnormal MAP (less than 70). Normal MAP is 70 to 100.

A client admitted with unstable angina is started on intravenous heparin and nitroglycerin. The client's chest pain resolves, and the client is weaned from the nitroglycerin. Noting that the client had a synthetic valve replacement for aortic stenosis 2 years ago, a physician writes an order to restart the oral warfarin (Coumadin®) 5 mg at 1900 hours. Which is the nurse's best action? 1. Administer the warfarin as prescribed. 2. Call the physician to question the warfarin order. 3. Discontinue the heparin drip and then administer the warfarin. 4. Hold the dose of warfarin until the heparin has been discontinued.

ANSWER: 1 Both heparin and warfarin are anticoagulants, but their actions are different. Oral warfarin requires 3 to 5 days to reach effective levels. It is usually begun while the client is still on heparin. Calling the physi- cian is unnecessary. The nurse's scope of practice does not permit altering medication orders. The nurse should neither discontinue the heparin nor hold the warfarin without a written order. ➧ Test-taking Tip: Use the process of elimination to eliminate options 3 and 4, which alter medication orders, because these are not within the nurse's scope of practice. Of the two remaining options, focus on the action of heparin and warfarin. Recall that warfarin takes 3 to 5 days to reach therapeutic effectiveness, during which time the client will continue to require anticoagulation.

Which physician's order should the nurse question for a newly admitted client diagnosed with diabetic ketoacidosis (DKA)? 1. D5W at 125 mL per hour 2.KCL 10 mEq in 100 mL NaCl IV now 3. Stat arterial blood gases. Administer sodium bicarbonate if pH is less than 7.0. 4. Regular insulin infusion per protocol adjusting dose based on hourly glucose levels

ANSWER: 1 In DKA, the blood glucose level is above 300 mg/dL. Additional glu- cose will only increase the glucose level. Initially 0.45% or 0.9% sodium chloride (NaCl) is administered for fluid resuscitation. Glucose may be added when blood glucose levels approach 250 mg/dL. Insulin will drive potassium into the cells, so potassium chloride (KCL) is admin- istered to prevent life-threatening hypokalemia. Normal pH is 7.35 to 7.45. Sodium bicarbonate will reverse the severe acidosis. Intravenous (IV) in- sulin will correct the hyperglycemia and hyperketonemia. Tight glucose control can be maintained by hourly glucose checks and adjusting the insulin infusion dose. ➧ Test-taking Tip: Note the key word "question." Select the option that would not be included in the treatment of the client with DKA.

A nurse should anticipate instructing a client scheduled for a coronary artery bypass graft to: SELECT ALL THAT APPLY. 1. discontinue taking aspirin prior to surgery. 2. perform postoperative cardiac rehabilitation exercises and stress management strategies. 3. wash with an antimicrobial soap the evening prior to surgery. 4. shave the chest and legs and then shower to remove the hair. 5. resume normal activities when discharged from the hospital. 6. expect close monitoring after surgery, several intravenous (IV) lines, a urinary catheter, endotracheal tube, and chest tubes.

ANSWER: 1, 2, 3, 6 Aspirin decreases platelet aggregation and increases the risk of bleed- ing. It is usually discontinued a few days prior to surgery. A postopera- tive cardiac rehabilitation program is begun usually on the second postoperative day and includes exercises and stress management. The client should use an antimicrobial soap when showering or bathing the evening before and the day of surgery to decrease the risk of infection. Teaching about expectations of close monitoring, IV lines, a urinary catheter, endotracheal tube, and chest tubes can reduce client and fam- ily anxiety. The client may be offered a tour of the critical care unit prior to surgery or be given videos to view. Although the client's skin will be shaved, this will be completed just prior to surgery to avoid nicks and decrease the risk of infection. Activities that stress the sternum, such as lifting, driving, and overhead reaching, will be restricted after surgery. ➧ Test-taking Tip: Use the process of elimination to eliminate options 4 and 5 because these increase surgical risk and the risk of complications after surgery.

Which instructions should the nurse provide to a client regarding diabetes management during stress or illness? SELECT ALL THAT APPLY. 1. Notify the health-care provider if unable to keep fluids or foods down. 2. Test fingerstick glucose levels and urine ketones daily and keep a record. 3. Continue to take oral hypoglycemic medications and/or insulin as prescribed. 4. Supplement food intake with carbohydrate- containing fluids, such as juices or soups. 5. When on an oral agent, administer insulin in addition to the oral agent during the illness. 6. A minor illness, such as the flu, usually does not affect the blood glucose and insulin needs.

ANSWER: 1, 3 An acute or minor illness can evoke a counterregulatory hormone re- sponse resulting in hyperglycemia, thus the client should continue medications as prescribed. If the client is unable to eat due to nausea and vomiting, dehydration can occur from hyperglycemia and the lack of fluid intake. Blood glucose should be checked every 4 hours when ill and the ketones tested every 3 to 4 hours if the glucose is greater than 240 mg/dL. The client should supplement the diet with carbohydrate-con- taining fluids only if eating less than normal due to the illness. Insulin may or may not be necessary; it is based on the client's blood glucose level. ➧ Test-taking Tip: Focus on the counterregulatory hormone response during an illness that causes hyperglycemia.

A nurse is planning care for a client admitted with a new diagnosis of persistent atrial fibrillation with rapid ventricular response. Although the client has had no previous cardiac problems, the client has been in atrial fibrillation for more than 2 days. The nurse should anticipate that the health-care provider is likely to initially order: SELECT ALL THAT APPLY. 1. oxygen. 2. immediate cardioversion. 3. administration of amiodarone (Cordarone®). 4. initiation of a IV heparin infusion. 5. immediate catheter-directed ablation of the AV node. 6. administration of a calcium channel antagonist such as diltiazem (Cardizem®).

ANSWER: 1, 3, 4, 6 The ineffective atrial contractions or loss of atrial kick with atrial fibrillation can decrease cardiac output. Administering oxygen enhances tissue oxygenation. Amiodarone is used for pharmacological cardioversion of the atrial fibrillation rhythm. The client is at risk for thrombi in the atria from stasis. Anticoagulant therapy is used to prevent thromboembolism. Diltiazem, a calcium channel antagonist, is prescribed to slow the ventricular response to atrial fibrillation. An alternative to a calcium channel antagonist would be the use of a beta blocker, such as esmolol, metoprolol, or propranolol. Cardioversion would only be considered if medications were ineffective in converting the client's rhythm and only after the presence of an atrial clot has been ruled out. Ablation of the AV node would only be considered if medications were ineffective in controlling the client's heart rate. ➧ Test-taking Tip: Carefully read the information provided in the stem. The key phrase is "initially order." The nurse should direct interventions at the client's potential complications from the arrhythmia. Note that both options 2 and 5 contain the words "immediate." Eliminate one or both of those options, because both procedures cannot be immediate.

A nurse increases activity for a client with an admitting diagnosis of acute coronary syndrome. Which symptoms experienced by the client best support a nursing diagnosis of activity intolerance? 1. Pulse rate increased by 15 beats per minute during activity 2. Blood pressure (BP) 130/86 mm Hg before activity; BP 108/66 mm Hg during activity 3. Increased dyspnea and diaphoresis relieved when sitting in a chair 4. A mean arterial pressure (MAP) of 80 following activity

ANSWER: 2 A drop in BP of 20 mm Hg from the baseline indicates that the client's heart is unable to adapt to the increased energy and oxygen demands of the activity. An increased heart rate during activity and the relief of dyspnea and diaphoresis with rest indicates the heart is able to adapt. A MAP of 80 is normal. ➧ Test-taking Tip: The key words are "best supports." Select the option that is an abnormal finding.

Following a normal chest x-ray for a client who had cardiac surgery, a nurse receives an order to re- move the chest tubes. Which intervention should the nurse plan to implement first? 1. Auscultate the client's lung sounds 2. Administer 4 mg morphine sulfate intravenously 3. Turn off the suction to the chest drainage system 4. Prepare the dressing supplies at the client's bedside

ANSWER: 2 Because the peak action of morphine sulfate is 10 to 15 minutes, this should be administered first. Auscultating the client's lungs before and after the procedure, turning off the suction, and assembling the dressing supplies are all necessary, but administering the analgesic should be first. ➧ Test-taking Tip: Recall that focusing on the client should be the priority.

A nurse is teaching a client who has been newly diagnosed with type 2 diabetes mellitus (DM). Which teaching point should the nurse emphasize? 1. Use the arm when self-administering NPH insulin. 2. Exercise for 30 minutes daily, preferably after a meal. 3. Consume 30% of the daily calorie intake from protein foods. 4. Eat a 30-gram carbohydrate snack prior to strenuous activity.

ANSWER: 2 Exercise increases insulin receptor sites in the tissue and can have a direct effect on lowering blood glucose levels. Exercise also contributes to weight loss, which also decreases insulin resistance. Usually type 2 DM is controlled with oral hypoglycemic agents. If insulin is needed, sites should be rotated. For those with DM, protein should contribute less than 10% of the total energy consumed. Strenuous activity can be perceived by the body as a stressor, causing a release of counterregulatory hormones that subsequently increases blood glucose. Hyperglycemia can result from the combination of strenuous activity and extra carbohydrates. ➧ Test-taking Tip: The key terms are "type 2" and "emphasize." Apply knowledge of type 2 DM and eliminate options 1, 3, and 4 because type 2 diabetics will produce some insulin, and often weight reduction, calorie reduction, and exercise will help to normalize glucose levels.

A nurse evaluates a client who is being treated for diabetic ketoacidosis (DKA). Which finding indicates that the client is responding to the treatment plan? 1. Eyes sunken, skin flushed 2. Skin moist with rapid elastic recoil 3. Serum potassium level is 3.3 mEq/L 4. ABG results are pH 7.25, PaCO2 30, HCO3 17

ANSWER: 2 Moist skin and good skin turgor indicate that dehydration secondary to hyperglycemia is resolving. Sunken eyes and flushing are signs of dehydration. Normal serum potassium levels are 3.5 to 5.8 mEq/L. The abnormal ABGs indicate compensating metabolic acidosis. ➧ Test-taking Tip: Note the key phrase "responding to treatment." Select the option that is a normal finding.

A client admitted with a diagnosis of acute coronary syndrome calls for a nurse after experienc- ing sharp chest pains that radiate to the left shoulder. The nurse notes, prior to entering the client's room, that the client's rhythm is sinus tachycardia with a 10-beat run of premature ventricular contractions (PVCs). Admitting orders included all of the follow- ing interventions for treating chest pain. Which should the nurse implement first? 1. Obtain a stat 12-lead electrocardiogram (ECG). 2. Administer oxygen by nasal cannula. 3. Administer sublingual nitroglycerin. 4. Administer morphine sulfate intravenously.

ANSWER: 2 Oxygen should be available in the room and should be initiated first to enhance oxygen flow to the myocardium. Though a stat 12-lead ECG is needed to identify ischemia or infarct location, the first action is to treat the client. Sublingual nitroglycerin dilates coronary arteries and will en- hance blood flow to the myocardium. Once oxygen is in place and the vital signs known, nitroglycerin should be administered. Morphine sulfate is a narcotic analgesic used for pain control and anxiety reduction. Because it is a controlled substance, extra steps are needed to retrieve the medication from a secure source, so this is not the first action. ➧ Test-taking Tip: Use the ABCs (airway, breathing, circulation) to establish the priority action. Improving oxygen flow to the myocardium is priority.

A female client is being treated with radioactive iodine (RAI) therapy for an enlarged thyroid gland. The client asks if there are any precautions that are needed during RAI therapy. Which is the nurse's best response? 1. "No precautions are necessary. You receive radiation in the form of a capsule that will target and destroy the thyroid tissue only." 2. "Though a pregnancy test has confirmed that you are not pregnant, use contraceptives or abstain from sexual intercourse to avoid conceiving during treatment." 3. "Because maximum effects may not be seen for 6 months, you will need to continue taking the antithyroid medication and propranolol until the effects of radiation become apparent." 4. "Although RAI is usually effective, a few individuals will need life-long thyroid hormone replacement due to posttreatment hypothyroidism."

ANSWER: 2 Pregnancy should be postponed for at least 6 months after treatment. RAI is contraindicated during pregnancy because it crosses the pla- centa. Approximately 5% of individuals require more than one dose to destroy overactive thyroid cells. Precautions about avoiding pregnancy should be advised. Almost all of the radioactive iodine that enters and is retained by the body is concentrated in the thyroid gland and destroys thy- roid tissue without jeopardizing other radiosensitive tissues. Symptoms of hyperthyroidism may subside in 3 to 4 weeks, but the maximum effects may not be seen for 3 to 4 months. Clients should continue with the an- tithyroid medication and propranolol. Almost 80% of individuals experi- ence posttreatment hypothyroidism. ➧ Te s t - t a k i n g T i p : T h e k e y w o r d i s " p r e c a u t i o n ." E l i m i n a t e o p t i o n 4 . Though correct, it does not address a precaution during RAI therapy.

An agitated client is admitted to the emergency department (ED) with tachycardia, dyspnea, and intermittent chest palpitations. The client has a blood pressure of 170/110 mm Hg and heart rate of 130 beats per minute. The client's health history reveals thinning hair, recent 10-lb. weight loss, increased appetite, fine hand and tongue tremors, hyperreflexic tendon reflexes, and smooth moist skin. A physician writes orders for the client. Which order should the nurse implement first? 1. Obtain 12-lead electrocardiogram (ECG). 2. Administer propranolol (Inderal®) 2 mg intravenously q10-15min or until symptoms are controlled. 3. Administer propylthiouracil (PTU) 600 mg oral loading dose followed by 200 mg orally q4h. 4. Obtain thyroid-stimulating hormone (TSH), free T4, and cardiac enzyme levels.

ANSWER: 2 The nurse should first administer propranolol as ordered by the physi- cian. Propranolol is a beta-adrenergic blocker for symptomatic relief of thyrotoxicosis and decreasing peripheral conversion of T4 to T3. It controls cardiac and psychomotor manifestations within minutes. A beta blocker is also a first-line treatment for a client with acute coro- nary syndrome. Dysrhythmias can occur from beta-adrenergic receptor stimulation caused by excess thyroid hormone or following an acute coro- nary syndrome. PTU will inhibit the synthesis of thyroid hormone. Clinical effects may be seen as soon as 1 hour after administration. Decreased TSH and elevated free T4 confirm the diagnosis of hyperthyroidism. Elevated cardiac enzymes confirm the diagnosis of acute coronary syndrome. ➧ Test-taking Tip: Use the ABCs (airway, breathing, circulation) to establish priority. Controlling the client's blood pressure and heart rate is priority.

A nurse administers 15 units of glargine (Lantus®) insulin at 2100 hours to a Hispanic client when the client's fingerstick blood glucose reading was 110 mg/dL. At 2300 hours, a nursing assistant reports to the nurse that an evening snack was not given because the client was sleeping. Which instruc- tion by the nurse is most appropriate? 1. "You will need to wake the client to check the blood glucose and then give a snack. All diabetics get a snack at bedtime." 2. "It is not necessary for this client to have a snack because glargine insulin is absorbed very slowly over 24 hours and doesn't have a peak." 3. "The next time the client wakes up, check a blood glucose level and then give a snack." 4. "I will need to notify the physician because a snack at this time will affect the client's blood glucose level and the next dose of glargine insulin."

ANSWER: 2 The onset of glargine is 1 hour, it has no peak, and it lasts for 24 hours. Glargine lowers the blood glucose by increasing transport into cells and promoting the conversion of glucose to glycogen. Because it is peakless, a bedtime snack is unnecessary. Options 1 and 3 are unnecessary and option 4 is incorrect. Glargine is administered once daily, the same time each day, to maintain relatively constant concentrations over 24 hours.

A nurse administers a usual morning dose of 4 units of regular insulin and 8 units of NPH insulin at 7:30 a.m. to a client with a blood glucose level of 110 mg/dL. Which statements regarding the client's insulin are correct? 1. The onset of the regular insulin will be at 7:45 a.m. and the peak at 1:00 p.m. 2. The onset of the regular insulin will be at 8:00 a.m. and the peak at 10:00 a.m. 3. The onset of the NPH insulin will be at 8:00 a.m. and the peak at 10:00 a.m. 4. The onset of the NPH insulin will be at 12:30 p.m. and the peak at 11:30 p.m.

ANSWER: 2 The onset of regular insulin (short-acting) is one-half to 1 hour, and the peak is 2 to 3 hours. The onset of NPH insulin (intermediate act- ing) is 2 to 4 hours, and the peak is 4 to 12 hours. All other options have incorrect medication onset and peak times.

A nurse is teaching a client newly diagnosed with chronic stable angina. Which instructions should the nurse incorporate in the teaching session on measures to prevent future angina? SELECT ALL THAT APPLY. 1. Increase isometric arm exercises to build endurance. 2. Wear a face mask when outdoors in cold weather. 3. Take nitroglycerin before a stressful situation even though pain is not present. 4. Perform most exertional activities in the morning. 5. Avoid straining at stool. 6. Eliminate tobacco use.

ANSWER: 2, 3, 5, 6 Blood vessels constrict in response to cold and increase the workload of the heart. Sexual activity and straining at stool increases sympathetic stimulation and cardiac workload. Nitroglycerin produces vasodilation and improves blood flow to the coronary arteries; it can be used prophylactically to prevent angina. Nicotine stimulates cate- cholamine release, producing vasoconstriction and an increased heart rate. Isometric exercise of the arms can cause exertional angina. Exer- tional activity increases the heart rate, thus reducing the time the heart is in diastole, when blood flow to the coronary arteries is the greatest. A period of rest should occur between activities and activities should be spaced. ➧ Test-taking Tip: The key phrase is "measures to prevent future angina." Consider if each option could potentially increase myocardial oxygen demand or decrease available oxygen, either of which could precipitate angina.

A nurse is assessing a client diagnosed with an anterior-lateral myocardial infarction (MI). The nurse adds a nursing diagnosis to the client's plan of care of decreased cardiac output when which finding is noted on assessment? 1. One-sided weakness 2. Presence of an S4 heart sound 3. Crackles auscultated in bilateral lung bases 4. Vesicular breath sounds over lung lobes

ANSWER: 3 An anterior-lateral MI can produce left ventricular dysfunction and low cardiac output. With low cardiac output, blood accumulates in the heart and backs up into the pulmonary system. The increased pul- monary pressure causes fluid to move into interstitial spaces and then into the alveoli. One-sided weakness suggests complications of a cere- brovascular accident, which can be caused from a clot or plaque embolus secondary to the MI. An S4 heart sound is produced when blood flows forcefully from the atrium to a resistant ventricle during late ventricular di- astole. Vesicular breath sounds are normal over lesser bronchi, bronchioles, and lobes of the lung. ➧ Test-taking Tip: Recall that an anterior MI can produce left ventricular dysfunction. Focus on the issue of an assessment finding indicative of low cardiac output. Eliminate option 1 because it relates to tissue perfusion. If unsure of option 2, move to option 3. Note that options 3 and 4 relate to the lungs, so one or both of these must be wrong. Recall that crackles are always abnormal, whereas the presence of S4 can be normal in an older adult, and vesicular lung sounds located over lung lobes is a normal finding.

A clinic nurse is evaluating a client with type 1 diabetes who intends to enroll in a tennis class. Which statement made by the client indicates that the client understands the effects of exercise on insulin demand? 1. "I will carry a high-fat, high-calorie food, such as a cookie." 2. "I will administer 1 unit of lispro insulin prior to playing tennis." 3. "I will eat a 15-gram carbohydrate snack before playing tennis." 4. "I will decrease the meal prior to the class by 15-grams of carbohydrates."

ANSWER: 3 Excessive exercise without sufficient carbohydrates can result in unex- pected hypoglycemia. The food should be a simple sugar food because the fat content of a high-fat food will delay the absorption of the glucose in the food. Taking insulin or decreasing the carbohydrate intake prior to ac- tivity will lower the blood glucose level such that hypoglycemia can occur. ➧ Test-taking Tip: Recall that type 1 diabetes mellitus requires daily insulin administration and that activity increases energy expenditure and the demand for glucose.

A nurse is evaluating a client's outcome. The client's nursing care plan includes the nursing diagnosis of fluid volume deficit related to hyperosmolar hyper- glycemic nonketotic syndrome (HHNS) secondary to severe hyperglycemia. The nurse knows that the client has a positive outcome when which serum laboratory value has decreased to a normal range? 1. Glucose 2. Sodium 3. Osmolality 4. Potassium

ANSWER: 3 Extreme hyperglycemia produces severe osmotic diuresis; loss of sodium, potassium, and phosphorous; and profound dehydration. Consequently, hyperosmolality occurs. A normalizing of the serum osmolality indicates that the fluid volume deficit is resolving. A decrease in serum glucose indicates that the hyperglycemia is resolving, but not the fluid volume deficit. Serum sodium and potassium values should increase, not decrease, with treatment. ➧ Test-taking Tip: Focus on the issue: deficient fluid volume.

Two hours after taking a regular morning dose of Insulin Regular (Humulin R®), a client presents to a clinic with diaphoresis, tremors, palpitations, and tachy- cardia. Which nursing action is most appropriate for this client? 1. Check pulse oximetry and administer oxygen at 2 L per nasal cannula. 2. Administer a baby aspirin, one sublingual nitroglycerin tablet, and obtain an electrocardiogram (ECG). 3. Check blood glucose level and provide carbohydrates if less than 70 mg/dL (3.8 mmol/L). 4. Check vital signs and administer atenolol (Tenormin®) 25 mg orally if heart rate is greater than 120 beats per minute.

ANSWER: 3 Humulin R is regular insulin that peaks in 2 to 4 hours after adminis- tration. The client's symptoms suggest hypoglycemia, so a blood glu- cose level should be checked. The symptoms do not suggest a respiratory problem (option 1). Though diaphoresis, palpitations, and tachycardia are symptoms of both hypoglycemia and cardiac problems, the client had taken insulin 2 hours earlier. Treating the low blood sugar first will likely resolve the client's symptoms. ➧ Test-taking Tip: Focus on the effects of Humulin R and the client's symptoms.

After an inferior-septal wall myocardial infarction, which complication should a nurse suspect when not- ing jugular venous distention (JVD) and ascites? 1. Left-sided heart failure 2. Pulmonic valve malfunction 3. Right-sided heart failure 4. Ruptured septum

ANSWER: 3 Right-sided heart failure produces venous congestion in the systemic circulation resulting in JVD and ascites (from vascular congestion in the gastrointestinal tract). Additional signs include hepatomegaly, splenomegaly, and peripheral edema. Left-sided heart failure produces signs of pulmonary congestion, including crackles, S3 and S4 heart sounds, and pleural effusion. A characteristic finding of pulmonic valve malfunc- tion would be a murmur. A murmur would also be auscultated with a rup- tured septum, and the client would experience signs of cardiogenic shock. ➧ Test-taking Tip: Note that options 1 and 3 focus on different types of heart failure. Either one or both of these must be wrong. Focus on the client's signs of JVD and ascites and the cardiac anatomy to eliminate all but option 3.

A nurse is instructing a client diagnosed with coro- nary artery disease about care at home. The nurse determines that teaching is effective when the client states: SELECT ALL THAT APPLY. 1. "If I have chest pain, I should contact my physician immediately." 2. "I should carry my nitroglycerin in my front pants pocket so it is handy." 3. "If I have chest pain, I stop activity and place one nitroglycerin tablet under my tongue." 4. "I should always take three nitroglycerin tablets, 5 minutes apart." 5. "I plan to avoid being around people when they are smoking." 6. "I plan on walking on most days of the week for at least 30 minutes."

ANSWER: 3, 5, 6 Stopping activity decreases the body's demand for oxygen. One nitro- glycerin tablet, taken sublingually, dilates the coronary arteries and increases oxygen to the myocardium. If pain is unrelieved, a second tablet should be taken 5 minutes later. Passive smoke can cause vaso- constriction and decrease blood flow velocity even in healthy young adults. The American Heart Association recommends exercising for 30 minutes on most days of the week. Medical attention is required only if pain persists and then the client should call 911 rather than the physician because emergency treatment may be necessary. Nitroglycerin loses its potency if stored in warm, moist areas, making the client's pants pocket an undesirable location for storage. If pain is relieved after one tablet, another tablet is not required. The standard dose for nitroglycerin is one tablet or spray 5 minutes apart until pain is relieved, to a maximum of three tablets. ➧ Test-taking Tip: The key words are "teaching is effective." Select the client statements that are correct.

A nurse notes that a client, who experienced a myocardial infarction (MI) 3 days ago, seems unusually fatigued. Upon assessment, the nurse finds that the client is dyspneic with activity, has a heart rate (HR) of 110 beats per minute (bpm), and has generalized edema. Which action by the nurse is most appropriate? 1. Administer high-flow oxygen 2. Encourage the client to rest more 3. Continue to monitor the client's heart rhythm 4. Compare the client's admission weight with the client's current weight

ANSWER: 4 A complication of MI is heart failure. Signs of heart failure include fatigue, dyspnea, tachycardia, edema, and weight gain. Other signs include nocturia, skin changes, behavioral changes, and chest pain. There is no indication that the client is hypoxic and in need of high-flow oxygen. To treat the dyspnea, oxygen by nasal cannula would be appropri- ate. The fatigue is caused by decreased cardiac output, impaired perfusion to vital organs, decreased tissue oxygenation, and anemia. Rest alone will not relieve the fatigue. Interventions are needed to improve cardiac output and tissue oxygenation. A heart rate of 110 bpm suggests tachycardia; the symptoms together imply heart failure. Further data collection is needed to confirm the findings. Continuing to monitor the client's heart rhythm, without further assessment, will delay an appropriate intervention. ➧ Test-taking Tip: Use the nursing process to determine the next action. Before a conclusion can be reached, additional data are needed.The nurse should complete the assessment process. Eliminate options 1 and 2 because these are interventions. Of options 3 and 4 determine which option would provide the most immediate information to make a conclusion about the data.

A nurse assesses a client who has just returned to a telemetry unit after having a coronary angiogram us- ing the left femoral artery approach. The client's baseline blood pressure (BP) during the procedure was 130/72 mm Hg and the cardiac rhythm was a normal sinus throughout. Which assessment finding should indicate to the nurse that the client may be ex- periencing a complication? 1. BP 144/78 mm Hg 2. Pedal pulses palpable at +1 3. Left groin soft with 1 cm ecchymotic area 4. Apical pulse 132 beats per minute (bpm) with an irregular-irregular rhythm

ANSWER: 4 An apical pulse of 132 (bpm) with an irregular-irregular rhythm could indicate atrial fibrillation or a rhythm with premature beats. Dys- rhythmias are a complication that can occur following coronary an- giogram. The client should be placed on a cardiac monitor to deter- mine the rhythm. A slight elevation of blood pressure could be related to pain at the incision site. It is not indicative of a complication without addi- tional data. Usually pulses are palpable at +2, but without additional base- line data on the clients' pulses, this warrants monitoring but is not indica- tive in itself of a complication. A soft groin area where the puncture site is located is a normal finding. Ecchymosis (bruising) does not indicate a complication. ➧ Test-taking Tip: Think about the potential complications that can occur after a coronary angiogram. Review each option to determine if the findings suggest a complication. Select the option that would be the most abnormal finding.

A nurse collects the following assessment data on a client who has no known health problems: blood pressure (BP) 135/89 mm Hg; body mass index (BMI) 23; waist circumference 34 inches; serum creatinine 0.9 mg/dL; serum K 4.0 mEq/L; low-density lipopro- tein (LDL) cholesterol 200 mg/dL; high-density lipoprotein (HDL) cholesterol 25 mg/dL; and triglyc- erides 180 mg/dL. Which order from the client's health-care provider should the nurse anticipate? 1. 1,500-calorie regular diet. 2. No added salt, low saturated fat, low-potassium diet. 3. Hydrochlorothiazide (HydroDIURIL®) 25 mg twice daily. 4. Atorvastatin (Lipitor®) 20 mg daily.

ANSWER: 4 Atorvastatin is used to manage hypercholesterolemia. It lowers the total serum LDL cholesterol and triglycerides and slightly increases HDL cholesterol by inhibiting 3-hydroxy-3-methylglutaryl-coenzyme A (HMG-CoA) reductase, an enzyme that is responsible for catalyzing an early step in the synthesis of cholesterol. For persons with 0-1 risk factors, the goal for LDL is less than 160 mg/dL (4.14 mmol/L), and drug therapy is considered when LDL is greater than or equal to 190 mg/dL (4.91 mmol/L). Normal triglycerides are 40 to 150 mg/dL (0.45-1.69 mmol/L). A low-calorie diet is not indicated. The normal BMI is 18.5 to 24.9. While a low-saturated-fat diet in option 2 is indicated, a low-potassium diet is not because the serum K of 4.0 mEq/L is normal. The client's BP is slightly elevated but would be initially treated with lifestyle changes, not a diuretic. ➧ Test-taking Tip: Focus on the data provided in the situation and identify the abnormal findings. If unable to identify the abnormal data because of lack of knowledge of normal lab values, note that the client's serum cholesterol level analysis includes more data than other problems. Conclude that these are abnormal data and then use "lipids" as a key to identifying the correct option. Review laboratory values and cardiac medications if you had difficulty with this question.

Which nursing diagnosis should a nurse include when developing a plan of care for a client with hypothyroidism? 1. Diarrhea related to gastrointestinal hypermotility 2. Imbalance nutrition: less than body requirements related to calorie intake insufficient for metabolic rate 3. Activity intolerance related to increased metabolic rate 4. Anxiety related to forgetfulness, slowed speech, and impaired memory loss

ANSWER: 4 Disturbed thought processes can cause the client to be anxious. Diarrhea, imbalance nutrition related to insufficient calories, and activity intolerance related to increased metabolic rate are nursing diagnoses ap- propriate for hyperthyroidism. ➧ Test-takingTip: Focus on the issue: nursing diagnoses for hypothyroidism. Look for key words in each option. Eliminate option 1 because of the key word "hypermotility." Eliminate option 2 because of the key phrase "calorie intake insufficient." Eliminate option 3 because of the key phrase "increased metabolic rate."

A nurse is caring for a client with type 2 diabetes on a telemetry unit. The client is scheduled for car- diac rehabilitation exercises (cardiac rehab). The nurse notes that the client's blood glucose level is 300 mg/dL and the urine is positive for ketones. Which nursing action should be included in the nurse's plan of care? 1. Send the client to cardiac rehab because exercise will lower the client's blood glucose level. 2. Administer insulin and then send the client to cardiac rehab with a 15-gram carbohydrate snack. 3. Delay the cardiac rehab because blood glucose levels will decrease too much with exercise. 4. Cancel the cardiac rehab because blood glucose levels will increase further with exercise.

ANSWER: 4 Exercising with blood glucose levels exceeding 250 mg/dL and ke- tonuria increases the secretion of glucagon, growth hormone, and cate- cholamines, causing the liver to release more glucose. Exercise in the presence of hyperglycemia does not lower the blood glucose level (options 1 and 3). Administering insulin may be an option, but the blood glucose level should be known before sending the client to cardiac rehab (option 2). ➧ Test-takingTip:Think about the physiological effects of stress on blood glucose levels.Then eliminate options 1 and 3 because these are incorrect. Of the remaining two options, decide which action is safest for the client.

A nurse, assessing a client hospitalized following a myocardial infarction (MI), obtains the following vital signs: blood pressure (BP) 78/38 mm Hg, heart rate (HR) 128, respiratory rate (RR) 32. For which life-threatening complication should the nurse care- fully monitor the client? 1. Pulonary embolism 2. Cardiac tamponade 3. Cardiomyopathy 4. Cardiogenic shock

ANSWER: 4 The symptoms are indicative of cardiogenic shock (decreased cardiac output leading to inadequate tissue perfusion and initiation of the shock syndrome). Pulmonary embolism, cardiac tamponade, and car- diomyopathy are causes of cardiogenic shock. The cause of this client's cardiogenic shock is a myocardial infarction. ➧ Test-taking Tip: Focus on the issue: life-threatening complications following MI.